Psoriasis is an autoimmune skin and joint disease that affects an estimated 2 to 3 percent of the world’s population. Those diagnosed with psoriasis have good reason to celebrate a new era in treatment that promises potentially safer and more effective results than past therapies. A decade ago most effective treatments posed significant health risks. The biotechnology revolution has improved this situation in the past three years.

• What is Psoriasis?
• What Causes Psoriasis?
• Who is at Risk?
• How to Prevent a Cold
• Quality of Life Issues
• Treatment
• Biologic Therapy for Psoriasis Has Arrived
• Summary and Final Thoughts

What is Psoriasis?

The name psoriasis originates from the Greek word psora (“to itch”). Psoriasis is an inflammatory disorder affecting skin and joints. It is not contagious and cannot be spread through direct personal contact. There are several types of skin psoriasis with their own unique signs and symp-toms.

The most common type of skin psoriasis is called “plaque-type” (also called ‘psoriasis vulgaris’), affecting about 80 to 90 percent of those with psoriasis. It appears as red, raised lesions (placques) covered with silvery-white scale. Plaques are commonly found on the joint surfaces of elbows and knees, low back, shins and scalp. They usually appear on the skin surface in a symmetric pattern, affecting right and left halves of the body. One measure of disease severity is based on the degree of thickness, redness and amount of scale associated with psoriatic plaques. Plaques are usually round or oval in shape, and scale can vary from thin, powdery flakes to firm thick crusts resembling oyster shell (ostraceous).

Another common severity index is the amount of skin surface area affected: 3 percent or less is considered mild, 3 to 10 percent moderate and more than 10 percent is severe skin disease (one palm-sized area is approximately 1 percent body surface area). Plaque-type psoriasis can affect the genitals and when these areas are involved men are more commonly affected than women. As the name implies, one of the main symptoms of the psoriatic plaque is itching and it is responsible for many of the psycho-social issues that typify this skin disease.

Other types include pustular psoriasis (red plaques covered with white pustules), inverse psoriasis (red scaly rash in the skin fold areas of groin and armpits), guttate psoriasis (so-called ‘rain-drop’ lesions that cover large surfaces of the body with small red spots) and erythrodermic psoriasis (total skin surface affected with redness, scaling, itching and often skin pain). In addition to these signs and symptoms, psoriasis commonly affects the fingernails and toenails with deformity (nail pitting and lifting), color changes and crumbling of the nail plates. These nail changes can progress to painful swelling and even loss of the nails.

Fifteen to thirty percent of those diagnosed with skin psoriasis develop a unique form of joint pain and stiffness called psoriatic arthritis.

Psoriatic arthritis is a chronic, progressive inflammatory disease of the joints. It most commonly affects the hands, wrists, neck, back, knees, feet and ankles. The most common joints affected are the end knuckles of fingers and toes. Nail changes often accompany psoriatic arthritis.

Pain and stiffness are usually worse in the morning or after inactivity and improve with physical activity. Severity can vary significantly between individuals, and onset of joint pain, swelling and tenderness can be slow or rapid. Tendons and ligaments of the small joints can be inflamed producing painful, swollen digits (dactylitis). Nearly 85 percent of adults with psoriatic arthritis developed skin psoriasis first, followed by joint disease.

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What Causes Psoriasis?

The exact cause of psoriasis remains unknown but it is a complex disease believed to have genetic, immunologic and environmental components. One third of people with psoriasis have a relative with the disease. If one or both parents have psoriasis, their children have a 10 percent or 50 percent chance of getting it, respectively. It is likely that several genes are involved in the development of psoriasis but why these genes work together to create the disease is unclear.

Psoriasis occurs when abnormal immune system signals cause skin cells to multiply too fast. The usual 30-day cycle is shortened to 3 to 4 days in skin areas affected by psoriasis, resulting in over-production of cells that pile up at the skin surface without shedding normally. This causes the typical red flaky plaques that can persist for months or years without treatment. Psoriatic arthritis occurs when these faulty signals cause in-flammation in the joint space, resulting in destructive pitting of the normally smooth joint surfaces, and causing stiffness, pain and swelling.

The activation of a type of white blood cell, called a T-cell, is the key immune system trigger for psoriasis and is responsible for many of its signs and symptoms. These signs and symptoms can be relieved in
several different ways, including blocking the activation of T-cells, or preventing the release of the T-cell factors that cause clinical skin and joint disease. Many of the new biologic agents specifically target these T-cell activities.

While genetic and immunologic factors appear to play important roles in psoriasis, environmental triggers are also involved. Most patients note flares of their disease in response to both internal and external cues such as emotional stress, skin injury, certain medications, climate changes (winter flares and summer calms) and specific types of infections (i.e. streptococcal). The exact role of these trigger factors in psoriasis remains unclear.

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Who is at Risk?

Psoriasis most often occurs between the ages of 15 and 35, but can appear at birth or more rarely in the elderly. Childhood onset is most fre-quently associated with infections like strep throat. There is no gender preference in psoriasis and certain ethnicities (e.g. West Africans,


African Americans, Japanese, Inuit and Native Americans) have much lower incidences. The number of Americans with psoriasis is estimated to exceed 7 million, with 150,000 - 250,000 new cases diagnosed each year. It is one of the most common skin problems that dermatologists see.

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How to Prevent a Cold

Psoriasis most often occurs between the ages of 15 and 35, but can appear at birth or more rarely in the elderly. Childhood onset is most fre-quently associated with infections like strep throat. There is no gender preference in psoriasis and certain ethnicities (e.g. West Africans,


African Americans, Japanese, Inuit and Native Americans) have much lower incidences. The number of Americans with psoriasis is estimated to exceed 7 million, with 150,000 - 250,000 new cases diagnosed each year. It is one of the most common skin problems that dermatologists see.

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Quality of Life Issues

Throughout history, and in many places today, the failure to differentiate between infectious skin diseases (e.g. leprosy, impetigo, herpes, scabies, etc.) and psoriasis have caused many patients to experience humiliation, shame, anger, sadness, depression and abandonment by their community and even family. This misconception is not the only reason why people with psoriasis can have these emotions; psoriasis is a life-long disease with frequent relapses and periods of remission.

Alcohol and drug abuse are often observed as coping mechanisms; ironically, these can be trigger factors for psoriatic flares. Reduction in physical and mental functioning comparable to that observed in individuals with cancer, diabetes, heart disease and depression have been reported by psoriasis patients.

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Treatment

There are many different treatments available to help patients with this disease. No single treatment works for everyone with psoriasis or psoriatic arthritis. The goal of all therapies is to maximize effectiveness with fewest side effects. Some people seek strictly Western medical approaches, while others seek alternative disciplines; others learn to use both. Alternative approaches include Ayurvedic medicine (ancient
Indian), Chinese herbal medicine, acupuncture, homeopathy and naturo-pathic medicine.

Sunlight and water (hot springs, mineral baths, Dead Sea spa centers) are natural psoriasis therapies used for thousands of years by many people seeking improvement or clearing of their skin and joint problems (albeit temporarily). Massage, meditation, yoga and biofeedback are mind and body approaches effectively used to reduce stress, directly improving psoriasis in many people. Changes in diet (losing weight, eliminating or reducing caffeine, alcohol, refined sugar and flour) and dietary supplements (fish oils, various herbs, zinc, iron, shark cartilage, etc.) are used by some to achieve improvement in their pso-riasis.

Except for sunlight and stress reduction most of these alternative approaches have little support among the mainstream U.S. medi-cal community. Patients are encouraged to seek medical doctors for their opinions.

Dermatologists classify psoriasis treatments into four categories: topicals, phototherapy (light treatment), traditional systemic therapy (oral agents) and new biologic agents. Patients with mild psoriasis usually improve with topicals and phototherapy quite well. Topical agents include various types of corticosteroids that differ in potency (weaker for face and fold areas of the body; stronger for joint surfaces, palms and soles), vitamin A and D derivatives, coal tar (ancient and effective agent), anthralin, and immunomodulators (new agents that affect immune responses). These topical medications can be used alone or in combination; dermatologists usually tailor specific topical regimes to the patient’s needs.

Light therapy is one of the oldest methods of treatment and consists of either natural sunlight every day or ultraviolet lamp therapy (i.e. UV light box), and a technique called PUVA ("Psoralen" combined with "UV-A" light). Psoralen is a systemic agent that makes the skin sensitive to UV light. All forms of light therapy can increase an individual’s susceptibility to getting skin cancer and thus dermatologists often will minimize its use in patients who are at high risk for skin cancer (e.g. fair skin, personal or family history, etc.).

Systemic treatments (e.g. retinoids, methotrexate and cyclosporine) are usually reserved for patients with moderate to severe forms of psoriasis or psoriasis that interferes with activities of daily life (e.g. palm and sole involvement, scalp and/or groin disease that is resistant to topicals, etc.). Most of the systemic agents have been used for many years by both rheumatologists and dermatologists. These drugs are usually very effective but have significant short- and long-term side effects (e.g. gastrointestinal, liver, bone marrow and kidney damage) that limit their use.

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Biologic Therapy for Psoriasis Has Arrived

Recent advances in genetic engineering have ushered in a new age of treatment for several inflammatory disorders, including both skin and joint psoriasis. Their effectiveness is comparable to or better than traditional systemic agents but with potentially less side effects.
However, these new treatments have not been used as long as
traditional systemic drugs and thus, little is known about the long-term consequences of their use.

Biologic agents are so named because they are derived from biological materials (proteins) that are synthesized by living cells. These purified proteins are the products of recombinant DNA-engineering techniques and are designed to block the action of immune reactions in the skin and joints. Each of the currently available biologics works to block
T-cell activities. Thus, unlike traditional systemic medications that have broad actions, biologic agents are tailored to target only one specific component that leads to inflammation of psoriasis.

There are five biologic agents currently approved for use in the U.S. to treat psoriasis and/or psoriatic arthritis. They are Enbrel, Humira, Remicade, Amevive and Raptiva. All are taken by injection and can cost $10,000 per year or more. Each of these agents has its own unique set of potentially harmful side effects (e.g. increased susceptibility to certain types of infections, temporary injection site reactions, mild flu-like symptoms, etc.), unique dosing and storage requirements. Short-term side effects are generally minor although allergic reactions can occur. Physicians and psoriasis patients are learning how to use these agents either alone or in combination with light therapy and
topical and/or other systemic agents. The majority of patients respond to treatment, but some do not.

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Summary and Final Thoughts

Psoriasis and psoriatic arthritis are common, relapsing autoimmune diseases. Their exact cause(s) is unknown but both genetic and environmental factors appear to contribute. Psoriasis has both medical and psychosocial impacts; more than half of all psoriasis patients report feelings of self-consciousness, embarrassment and anxiety in social situations.

The most exciting area in the field of psoriasis has been our recent increased understanding of disease development and the crafting of new biologic agents that specifically target this complex process. Psoriasis patients achieve a sense of control by actively pursuing treatment options and learning to cope with their particular disease. These coping strategies include seeking medical care from healthcare professionals, joining patient advocacy and support groups, lifestyle and job changes, and above all, being optimistic.
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