Psoriasis

In this article:

• How is psoriasis diagnosed?
• Duration of Psoriasis
• Treatment for psoriasis
• Medications
• Topical therapies
• Systemic therapies
• Off-label medications
• Phototherapy
• Climatotherapy of psoriasis
• What is NEW?
• Living with psoriasis
• Emotional health
• Diet modification to relieve psoriasis
• Prevention of Psoriasis
• Reference

---

How is psoriasis diagnosed?

The diagnosis of psoriasis is primarily clinical. There are different clinical types of psoriasis. The most common is chronic plaque psoriasis, affecting 80% to 90% of patients with this disease.

The hallmark of classic plaque psoriasis is well-demarcated, symmetric plaques with overlying silvery scale, on a red inflamed skin. Plaques are typically located on the scalp, trunk, buttocks, and extremities but can occur anywhere on the body. Active psoriasis rash might be itchy or painful. Psoriasis can also present as an isomorphic response, where new lesions develop on previously normal skin that has sustained trauma or injury. 

The severity of disease can be helpful in guiding management and is classified as

1. Mild 
2. Moderate
3. Severe.

Less common variants of psoriasis include inverse psoriasis, pustular psoriasis, guttate psoriasis, erythrodermic psoriasis, and annular psoriasis. These variants can be differentiated from the common plaque type by a skilled dermatologist. 

Differential diagnoses include atopic dermatitis, contact dermatitis, lichen planus, secondary syphilis, mycosis fungoides, tinea corporis, and pityriasis rosea. Careful observation often yields the diagnosis. For more atypical presentations, a skin biopsy might be helpful.

CLINICAL DIAGNOSIS OF PSORIASIS:

Plaque psoriasis		Well circumscribed, erythematous, scaly plaques > 0.5 cm in diameter, either as single lesions or as generalized disease. Classified further according to anatomic sites involved
		Flexural (intertriginous or inverse psoriasis). Well circumscribed, minimally scaly, thin plaques localized to the skin folds (inframammary, axillary, groin, genital, natal cleft regions)
		Nail psoriasis. Can present without concomitant skin plaques. Pitting, distal onycholysis, subungual hyperkeratosis, oil drop sign, splinter hemorrhages, leukonychia, crumbling, red lunula. Nail involvement is a sign that psoriatic arthritis can develop too.
		Scalp psoriasis. One of the most common sites of psoriasis. Often difficult to treat
		Palmoplantar. Localized to the hands and soles of feet. Confluent redness and scaling without obvious plaques to poorly defined scaly or fissured areas to large plaques covering the palm or sole
Guttate psoriasis		Acute eruption of “dew-drop,” salmon-pink, fine-scaled, small papules on the trunk or limbs. Can follow history of group A streptococcal pharyngitis or perianal group A streptococcus dermatitis
Pustular psoriasis		Sheets of monomorphic pustules on painful, inflamed skin. Most commonly localized to the palms or soles
Erythroderma		Acute or subacute onset of generalized erythema covering 90% or more of the patient’s entire body with little scaling Might be associated with hypothermia, hypoalbuminemia, electrolyte imbalances, and high-output cardiac failure Life-threatening emergency
Annular psoriasis		Well demarcated erythematous scaly plaques with central clearing

---

Duration of Psoriasis

Psoriasis is a chronic disease that is estimated to affect approximately 1 – 4% of population. Psoriasis is a multisystem inflammatory disease with predominantly skin and joint involvement. It has a bimodal age of onset (16 to 22 and 57 to 60 years), and affects both sexes equally.

Only some people can get rid of psoriasis once it begins. Despite its considerable effect on quality of life, psoriasis is underdiagnosed and undertreated.

---

Treatment for psoriasis

Although there is no cure for psoriasis, there are multiple effective treatment options. Topical therapy is the standard of care for treatment of mild to moderate disease. A large proportion of patients would benefit from topical therapy, which can be initiated at the primary care level. 

If topical treatment did not help much, or if rash covers a significant area of the body hard to cover with creams, you can be referred for assessment by a dermatologist. At this point, systemic therapy, while continuing topical care, might be considered. Presence of psoriatic arthritis might also call for systemic therapies in collaboration with a rheumatologist.

Medications

Plenty of treatments are available for people with psoriasis. It is always best to start from topical medications that have least side effects. First line of treatment can be recommended by a primary care practitioner, while more advanced biologicals should be given under a specialist’s guidance.

Topical therapies

Corticosteroids: Considered the cornerstone of topical treatment, corticosteroids are often well tolerated and effective for patients with mild psoriasis. Despite widespread use for more than half a century, large RCTs and head-to-head comparisons are rather limited. A literature review however, showed that corticosteroids performed at least as well as vitamin D3 analogues. Overall, topical steroids in various formulations, strengths, and combinations are efficacious initial therapy for rapid control of symptoms. 

For instance, salicylic acid, a keratolytic agent, can be combined with steroid therapy to help treat plaques with thicker scales, for better penetration of medication. Although uncommon, long-term use is complicated by possible side effects of local skin changes, tachyphylaxis, and hypothalamic-pituitary-adrenal axis suppression.

Vitamin D3 analogues: Calcipotriol, a vitamin D3 analogue, is a first-line topical agent for treatment of plaque psoriasis and moderately severe scalp psoriasis. Multiple randomized trials have shown calcipotriol to be safe and efficacious for patients with mild plaque psoriasis and not inferior to most corticosteroids with respect to efficacy. 

Further, a review of available data showed that vitamin D3 analogues are more effective than all other topical medications, except the most potent of corticosteroids; for twice-daily becocalcidiol and once-daily paricalcitol, respectively. 

Given their efficacy and safety profile, vitamin D3 analogues are commonly used as monotherapy or, more often, as combination therapy. Side effects include mild irritant dermatitis and rarely hypercalcemia with excessive use. These agents should not be used in combination with salicylic acid or before phototherapy.

Combination products: Combination of calcipotriol and betamethasone dipropionate was shown to be more effective for psoriasis than either monotherapy alone. Clinical trials have also demonstrated reduced incidence of adverse events with concomitant or sequential use of vitamin D3 analogues and topical corticosteroids.

Systemic therapies

Acitretin: Acitretin is a synthetic retinoid indicated for treatment of moderate to severe psoriasis. Its role as an adjunctive therapy to other systemic agents has been well documented to enhance efficacy, lower doses, and reduce occurrence of side effects. Common side effects include mucocutaneous dryness, arthralgia, gastrointestinal upset, and photosensitivity. This medication can sometimes cause transaminitis and elevated triglyceride levels. Acitretin is a potent teratogen that is best avoided in women of childbearing age and potential; it is recommended that women not get pregnant for 3 years after discontinuing the medication.

Methotrexate: Methotrexate is an inhibitor of folate biosynthesis, used for its cytostatic and anti-inflammatory properties in the treatment of moderately severe to severe psoriasis, as well as psoriatic arthritis. Despite substantial clinical experience with this drug, large robust studies of its efficacy and safety are extremely limited. A well-known side effect is hepatotoxicity. Other more common side effects include nausea, vomiting, diarrhea, and fatigue.

Cyclosporine: Cyclosporine is a calcineurin inhibitor indicated for treatment of moderate to severe psoriasis. There is also some evidence for its efficacy in psoriatic arthritis. It has been shown to cause significant improvement or complete remission in 80% to 90% of patients within 12 to 16 weeks in a 1-year open, multicentre, randomized study with 400 patients.

Advantages over other systemic agents include rapid onset of action and less concern about myelosuppression or hepatotoxicity. Adverse effects include nephrotoxicity, hypertension, elevated triglyceride levels, gingival hyperplasia, tremors, hypomagnesemia, hyperkalemia, numerous drug interactions, and malignancies such as skin cancers and lymphoma.

Off-label medications

Although most psoriasis patients respond to standard therapies, many circumstances warrant the use of nonstandard or off-label treatments. For instance, patients with treatment-resistant psoriasis or those who have had multiple adverse effects to other therapies may be good candidates for off-label treatments. 

Similarly, patients with unusual and hard-to-treat forms of psoriasis such as pustular psoriasis and palmoplantar psoriasis or specific comorbidities may benefit from certain nonstandard therapies. Drugs that may be used as alternatives to standard therapies include mycophenolate mofetil, tacrolimus or pimecrolimus, isotretinoin, colchicine, sulfasalazine, paclitaxel, dapsone, azathioprine, and hydroxyurea. 

Other unconventional therapies include climatotherapy at the Dead Sea and grenz ray therapy.

Phototherapy

Phototherapy is a mainstay treatment of moderate to severe psoriasis, especially in psoriasis that is unresponsive to topical agents.1 It is available as psoralen plus UVA, broadband UVB, and narrowband UVB (NB-UVB). Owing to its efficacy and safety advantages, as shown in multiple RCTs, NB-UVB therapy is often used as first-line treatment. In fact, NB-UVB therapy can be given to almost any patient, including children and pregnant women. 

There is no evidence that NB-UVB increases the risk of skin malignancy. Despite its safety, limited availability of phototherapy centres and the need for frequent visits (3 times a week for 3 months initially) puts this option as extremely inconvenient for patients.

---

Climatotherapy of psoriasis

It is known for a while now that people go to specific destinations in the World to cure psoriasis. One of the particularly famous places is Dead Sea in Israel. Here is a scientific paper discussing climatotherapy.

Climatotherapy of psoriasis

Jana Kazandjieva , Ivan Grozdev, Razvigor Darlenski, Nikolai Tsankov  Review. Clin Dermatol  Oct 2008;26(5):477-85. doi: 10.1016/j.clindermatol.2008.05.001.

Abstract

In the era when biological treatments for psoriasis are gaining more and more popularity, climatotherapy represents a safe and efficient alternative to the conventional therapeutic modalities. Climatotherapy comprises alternative treatment methods, which are based on the healing capacities of natural resources. This paper provides the reader with relevant information on the different climatotherapeutic methods, the intimate mechanisms of their action, and the cumulated clinical experience in the treatment of psoriasis. 

The positive effect of thalassotherapy for psoriasis has been known since ancient times. However, in the past decades a number of controlled studies revealed the efficacy of thalassotherpay in the treatment of psoriasis. Herein, it is exemplified on the experience in the centers at the Dead Sea and the Black Sea coast. 

Originating from Europe, balneo- and spa therapy are becoming popular alternatives for psoriasis treatment worldwide. A short review on the centers profiled for psoriasis therapy is provided. The unique sites of Blue Lagoon in Iceland and Kangal in Turkey are selected in this paper. Additionally, alternative nature-based treatments for psoriasis such as high mountain climatotherapy and naphtalotherapy are discussed.

---

What is NEW?

Biologic therapy: Biologics have emerged as highly potent treatment options in patients for whom traditional systemic therapies fail to achieve an adequate response, are not tolerated owing to adverse effects, or are unsuitable owing to comorbidities. There is no single sequence in which biologics should be initiated or switched; however, a meta-analysis of pivotal phase III studies has shown that infliximab might be the most efficacious, followed by ustekinumab, adalimumab, and etanercept.

Choice of therapy depends on clinical needs, benefits and risks, patient preferences, and cost effectiveness (around $20 000 to $25 000 a year on average). Previous randomized trials and retrospective studies have shown that biologic therapy was not associated with increased risk of malignancy or serious infection.

---

Living with psoriasis

Psoriasis is a life-long condition for most people, once it presents itself. It carries psychological, emotional and financial problems that have to be taken into account.

Emotional health 

The links between psoriasis and stress are complex. This article proposes a review of the literature on the relationship between stress and psoriasis. In 31-88% of cases, patients report stress as being a trigger for their psoriasis. There was also a reported higher incidence of psoriasis in subjects who had a stressful event the previous year, suggesting that stress may have a role in triggering the disease in predisposed individuals. 

Stress is also a consequence of psoriasis outbreaks. Understanding the role of stress makes it appropriate to target stress when proposing treatment to patients with psoriasis. Several controlled studies have demonstrated that relaxation, hypnosis, biofeedback, and behavioral and cognitive stress management therapies have been effective in people with psoriasis.

---

Diet modification to relieve psoriasis

Among the risk factors for psoriasis, evidence is accumulating that nutrition plays a major role, per se, either in the pathogenesis of psoriasis or in affecting drug pharmacokinetics and pharmacodynamics. However, in the vast majority of the results it is difficult to discriminate between the effect of weight loss and dieting per se.

Severe psoriasis has been associated with nutritional deficiencies because of an accelerated loss of nutrients from the hyperproliferation and desquamation of the epidermal layer of skin. Indeed, in severe cases the psoriasis can result in an insufficient nutritional status which may even be promoted by nutrient-drug interactions. Limited data exist regarding the role of specific diet regimens in psoriasis, mainly with the aim to reduce cardiac risk factors and obesity-related comorbidities. Previous studies or single case reports reported the positive effects of low-energy diets and vegetarian diets, formula diet weight loss programmes, gluten-free diet, very low-calorie carbohydrate-free (ketogenic). 

Fasting periods or vegetarian diets, and diets rich in omega-3 polyunsaturated fatty acids (ω-3 PUFA) from fish oil have been associated with improvement of psoriasis in clinical trials. In this, the reduced amounts of arachidonic acid and the increased eicosapentaenoic acid intake might result in an anti-inflammatory environment. 

Some psoriatic patients are gluten-sensitive and may benefit from a gluten-free diet. It is believed that some vitamins (A, E and C), and oligoelements (iron, copper, manganese, zinc, and selenium) have anti-oxidants ability, which decrease oxidative stress and the production of reactive oxygen species. 

In addition, along with improving glucose, insulin and lipid control, food fibres also play an important role in systemic inflammation, by decreasing the oxidative stress produced by the elevated intake of high-simple carbohydrate foods. Finally, due to its role in proliferation and maturation of keratinocytes, vitamin D has become an important therapeutic option in the treatment of psoriasis.

Monounsaturated fatty acids (MUFA) are considered a healthy dietary fat, as opposed to saturated fatty acid. The most frequently consumed MUFA rich dietary oils is extra virgin olive oil (EVOO). Traditionally, the beneficial effects of EVOO have been attributed to its high MUFA content (oleic acid), as it protects lipoproteins and cellular membranes from oxidative damage. 

Additionally, the relationship of psoriasis with either individual nutrients or individual food groups, it should be kept in mind that diet is a complex combination of foods from various groups and nutrients, and some nutrients are highly correlated. 

Recent evidence has confirmed that adherence to a healthy diet over time reduces the risk of long-term inflammation. 

The traditional Mediterranean diet is a healthy diet characterised with the abundance of vegetable foods and cereals, such as green and yellow vegetables, salads, legumes, bread, pasta, fruits and nuts. It is a highly palatable and favourable diet, and may lead to a higher adherence among dieters in the long term. 

EVOO is the main source of fat and the intake of fish, poultry, dairy products, and eggs is moderate. In addition, different amounts of wine are usually consumed in moderation with meals. Animal fats used in butter, cream, and lard are not included in this diet. 

In addition, other nutrient and non-nutrient components of MD foods, such as β-carotene, zinc, selenium, vitamin C, and vitamin E, have been shown to be associated with lower levels of markers of inflammation. In particular, the flavonoid compounds present in vegetables, the most important sources of phenolic, are considered to mainly provide the antioxidant effects. 

Vegetables are also an important source of phytosterols that reduce cholesterol serum levels and, subsequently, the cardiovascular risk. Protective actions against oxidative mechanisms are also exerted by fruits, other basic element of the MD, due to the high amount of fibres, vitamins, minerals, flavonoids, and terpenes. 

Finally, the dairy products of the MD, such as yoghurt, are better tolerated by the lactose-intolerant subjects and might induce favourable changes in the gut microflora, with positive effect also on the risk of colon cancer.

The nutritional assessment, based on body composition, and lifestyle modifications should be an integral component of management of the psoriatic patients. These “easy” concepts might be of strategic relevance in terms of clinical efficacy and cost-effectiveness of the newer biological drugs. 

A diet regimen rich in MUFA and ω-3 PUFA, fruits, vegetables, fibre, with the reduced intake of saturated fats, simple carbohydrates, and sweetened drinks, should be recommended to the psoriatic patients. The role of nutritional supplements has been extensively evaluated in a recent review. Nutrition and dietetic recommendations might be summarized as follows:

1. Foods to include: 

• Cold water fish, such as salmon, herring, mackerel, and trout, due to their content in ω-3 PUFA and vitamin D. It is recommended especially to prefer wild fish (not farmed), to also prevent the ingestion of harmful chemicals and toxic additives. Flaxseed and evening primrose oil might be also used as additional dietary sources.
• Whole grains, legumes, vegetables, and fruits as rich source dietary fibre, trace elements, including zinc and selenium, and vitamins. In particular, orange and yellow vegetables contain vitamin A, pumpkin seeds that provide zinc, often deficient in patients with psoriasis [85], and brewer’s yeast, as its content in vitamin B12 has been reported to be effective in improving the psoriatic skin lesion.

2. Foods to avoid: 

• Alcohol, gluten, given the higher prevalence of celiac disease among psoriatic patients, red meat, and dairy products, due to their high content in saturated fat, peppers; the association between caffeine, including coffee, tea black, mate, dark chocolate, remains still to be ascertained.

In addition to fish oil rich in ω-3 PUFA, other dietary supplements with vitamin D and B12 or selenium still need further evidence on their clinical effectiveness in large population samples.

---

Prevention of Psoriasis

While no one found out how to prevent psoriasis, there is plenty of knowledge supporting this skin condition with unhealthy habits, poor quality of food, stress and overworking. As such, we suggest that you take good care of your body, as skin is a large part of it. It you do not know which diet is best for you, we recommend to take a consultation from a knowledgeable dietitian or nutritionist. A doctor of Natural Medicine or a Functional Physician may help you figure out best way to prevent or treat psoriasis naturally.

---

Reference

Diagnosis and management of psoriasis. Kim WB, Jerome D, Yeung J.Can Fam Physician. 2017 Apr;63(4):278-285.PMID: 28404701 Free PMC article. Review.

Risk Factors for the Development of Psoriasis. Kamiya K, Kishimoto M, Sugai J, Komine M, Ohtsuki M.Int J Mol Sci. 2019 Sep 5;20(18):4347. doi: 10.3390/ijms20184347.PMID: 31491865 Free PMC article. Review.

New Treatment Addressing the Pathogenesis of Psoriasis. Tokuyama M, Mabuchi T.Int J Mol Sci. 2020 Oct 11;21(20):7488. doi: 10.3390/ijms21207488.PMID: 33050592 Free PMC article. Review.

Psoriasis Pathogenesis and Treatment. Rendon A, Schäkel K.Int J Mol Sci. 2019 Mar 23;20(6):1475. doi: 10.3390/ijms20061475.PMID: 30909615 Free PMC article. Review.

A clinical review of phototherapy for psoriasis. Zhang P, Wu MX.Lasers Med Sci. 2018 Jan;33(1):173-180. doi: 10.1007/s10103-017-2360-1. Epub 2017 Oct 24.PMID: 29067616 Free PMC article. Review.

Barrea, Luigi et al. “Environmental Risk Factors in Psoriasis: The Point of View of the Nutritionist.” International journal of environmental research and public health vol. 13,5 743. 22 Jul. 2016, doi:10.3390/ijerph13070743 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4962284/