Psoriasis is a chronic, inflammatory condition characterized by pink, scaly plaques, usually on the extensor surface of the arms and legs, but can occur on other areas of the body. It can be associated with joint pain and increased risk of heart attack and stroke.
Psoriasis is due to genetic predisposition and environmental triggers, such as infections, medications, emotional stressors, alcohol intake, and injury to the skin. Guttate psoriasis, which is characterized by pink, scaly papules on the trunk, is often preceded by sore throat caused by a streptococcus infection. Medications such as lithium and beta-blockers can trigger psoriasis.
Psoriasis can occur at any age and patients present with pink, scaly plaques, usually on the extensor surface of the arms and legs. They also commonly occur on the scalp, face, trunk, palms, and soles. Inverse psoriasis is the presence of pink plaques on the body folds such as the armpits, between the buttocks, and the groin. Pustular psoriasis is characterized by the presence of pus bumps or pustules, occurring especially on the hands and feet. Lesions can be associated with itching, especially during flares. Other findings of psoriasis include nail changes, including the development of nail pitting and debris under the nail plate, and arthritis at rest from increased inflammation of the joint and destruction of the bone, especially on the fingers, toes, knees, and lower back. Patients can develop stiffness of joints and redness and swelling of fingers, resulting in sausage digits.
Patients can have a family history of psoriasis. The inflammatory response is often triggered by trauma to the skin, infections, emotional stressors, and medications. Alcohol intake, obesity, and smoking have been reported as risk factors for developing psoriasis.
Psoriasis is a clinical diagnosis, characterized by well demarcated, scaly pink plaques, especially on the extensor surface of the arms and legs, scalp, face, and trunk. Patients may have involvement of nail plate and joint pain, especially on the fingers, toes, knees, and lower back.
There are multiple levels of treatment options for psoriasis, depending on the body surface area and degree of joint pain. Patients who are experiencing mild lesions on limited areas of the body can benefit from treatment with topical steroids, as it decreases inflammation. The addition of Vitamin D3 topical medications also decreases inflammation and epidermal thickening to help normalize the skin. Topical calcineurin inhibitors such as pimecrolimus and tacrolimus do not cause stretch marks or atrophy and can be used to treat lesions on the face and skin folds, such as the inner thighs. Salicylic acid based shampoos can help reduce thickness of lesions on the scalp. Other topical treatments that have been recently developed include roflumilast cream 0.3%, which is a phosphodiesterase inhibitor with strong anti-inflammatory properties, and taparinof cream 1%, a topical aryl hydrocarbon receptor that decreases the expression of inflammatory cells and improves the skin barrier.
Patients with more extensive psoriasis may also benefit from narrow band ultraviolet B (NBUVB) treatment. NBUVB uses a safe wavelength that does not cause skin cancer to reduce inflammation and can be administered in a booth or through excimer laser treatment. These treatments are not offered at New Bloom Dermatology and are usually administered two to three times a week.
Patients who have extensive psoriasis, with or without arthritis, can benefit from systemic medications, such as oral phosphodiesterase inhibitors and injected biologics. Apremilast is an oral phosphodiesterase inhibitor that helps decrease intracellular inflammation and itching. The main side effects of the medication include diarrhea, weight loss, and depression. Biologic therapies target the immune cells involved in psoriasis and have successfully decreased body surface involvement and arthritis. Etanercept, adalimumab, and infliximab target tumor necrosis factor alpha. However, these medications can be associated with increased risk of opportunistic infections and lymphomas. Ixekizumab, secukinumab, and brodalumab target interleukin-17A. These medications can also increase the risk of inflammatory bowel disease and candidal infections. Ustekinumab blocks interleukin-12 and interleukin-23 (IL-23), which consequently decreases inflammation associated with psoriasis. It can increase the risk of infection and certain malignancies, such as squamous cell carcinomas of the skin. Risankizumab targets IL-23, but can increase the risk of upper respiratory and fungal skin infections. JAK inhibitors such as tofacitinib (JAK 1 and 3 inhibitor) and upadacitinib (JAK 1 inhibitor) inhibit the production of cytokines responsible for psoriasis. However, they are associated with increased risk of blood clots, heart attack, lymphoma, lung cancer, and infection. Deucravacitinib is an oral tyrosinase kinase 2 inhibitor that decreases IL-23 signaling and inhibits the production of IL-17. Side effects of Deucravacitinib include reactivation of herpes virus and tuberculosis and the development of folliculitis, lymphomas, and rhabdomyolysis or breakdown of muscle. These medications are not prescribed by the providers at New Bloom Dermatology.
Patients who develop guttate psoriasis as a result of streptococcal pharyngitis would benefit from oral antibiotic treatments such as azithromycin or amoxicillin along with topical treatment on affected lesions.
Patients diagnosed with psoriasis are advised to reduce alcohol consumption and address emotional stressors. Furthermore, patients should have yearly checks with their primary care doctor to evaluate their cardiovascular health and any possible joint pain.
Patients who do not seek treatment of psoriasis are at risk of developing worsening plaques, heart disease, stroke, and significant arthritis as a result of inflammation and bony destruction. They are also at risk of increased anxiety and depression.
Psoriasis patients can have joint pain and are at increased risk of heart attack and stroke.
Individuals are recommended to see a board-certified dermatologist for further management of skin findings. Furthermore, they are recommended to see their primary care physician for a history and physical and check their lipid panel, as they are at risk for cardiovascular disease. Individuals who are experiencing joint pain should receive further evaluation by a rheumatologist for appropriate diagnosis and management.
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