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General Management of Difficult Psoriasis

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General Management of Difficult Psoriasis

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Here, I have discussed about the general management of difficult psoriasis and the prevention of its exacerbation.

Written by

Dr. Suvash Sahu

Medically reviewed by

iCliniq medical review team

Published At November 24, 2016
Reviewed AtNovember 24, 2023

Introduction

Psoriasis is a chronic genetically influenced immunologically based inflammatory disease of skin and joints. A majority of patients can be managed with topical coal tar, Dithranol and corticosteroids. However, psoriasis has a tendency to recur and may become worse. Moderate to severe psoriasis defined as more than 20% or more body surface area or patient unresponsive to topical therapy are termed as difficult psoriasis.

Types of Difficult Psoriasis

  1. Psoriatic erythroderma means psoriatic lesions involving more than 90% body surface area.
  2. Pustular psoriasis, psoriatic plaques developed with pus filled lesions.
  3. Psoriatic arthritis.
  4. Palmoplantar and scalp psoriasis.
  5. Plaque psoriasis not responding to conventional therapy.

How to Assess Psoriasis Patients?

The patient presenting with psoriasis requires a welcoming and sympathetic approach. To understand their condition and aggravating factors, the overall assessment, including patient perception and expectation, life style, other diseases and drugs should be made. Also, previous treatment and their effectiveness and side effects have to be assessed.

Factors Causing Exacerbation of Psoriasis

Stress, alcohol, smoking, trauma, sun, oral corticosteroids, beta blockers, Lithium, drugs used to treat malaria, painkillers, etc.

Treatment

1) Scalp Psoriasis:

Scalp to be drenched overnight with coconut oil based coal tar and salicylic acid pomade and cover with a shower cap or polyethylene cap. Shampoo the hair only the next morning and use a comb to remove the scales in the scalp. Use potent steroid lotion daily or intermittently. Narrow band UVB (ultraviolet B) is also very effective in scalp psoriasis.

2) Palmoplantar and Pustular Psoriasis:

Topical PUVA (psoralen and ultraviolet A radiation) is the most effective in palmoplantar psoriasis. PUVA usually leads to clearing and may produce long-lasting remissions. For pustular psoriasis, Acitretin is the drug of choice. The usual dose given is 1 mg/kg/day.

3) Psoriatic Arthropathy:

In this type, Methotrexate is the drug of choice. Biologics will also play a role in psoriatic arthritis.

4) Psoriasis in Pregnancy:

Psoriasis in pregnancy is usually managed by topical therapies. Generalized pustular psoriasis of pregnancy is best treated with oral Prednisolone. Cyclosporine is claimed to be compatible with pregnancy, but safety is not established.

5) Psoriasis in Children:

Retinoid appears to be the drug of choice for children, 0.25 to 0.6 mg/kg is the recommended dose. Monitoring with bone scan every 12 to 18 months is recommended for children on retinoid.

Frequently Asked Questions

1.

Which Regime Is Mostly Used to Treat Psoriasis?

Topical corticosteroid ointments and creams are the most commonly used treatment against psoriasis. These ointments vary in strength, so a specialist must be consulted before application. Additionally, vitamin D analogues, calcineurin inhibitors, coal tar, dithranol, phototherapy, and drugs like Methotrexate, Cyclosporin, and Acitretin are also included in psoriasis care.

2.

hich Is the Ideal Standard of Care for Psoriasis?

The ideal standard of care for psoriasis involves topical corticosteroids, ultraviolet therapy, vitamin D2 analogues, and a combination of calcipotriol and betamethasone dipropionate. Systemic treatment involves Acitretin (synthetic retinoid), Methotrexate, Cyclosporine, Infliximab, Ustekinumab, and Adalimumab.

3.

What Can Be Done to Prevent the Spread of Psoriasis?

To prevent the spread of psoriatic lesions:
- Use moisturizers.
- Take good skin care.
- Avoid dry and cold environments.
- Use humidifiers.
- Avoid the triggering drugs.
- Avoid skin traumas.
- Moderate exposure to sunlight.
- Reduce stress.
- Control alcohol consumption.
- Make healthy lifestyle choices.

4.

Which Food Items Are Contraindicated in Psoriasis?

Certain food items are contraindicated for psoriasis:
- Red meat.
- Dairy products.
- Gluten-rich foods.
- Processed foods.
- Nightshade food items.
- Alcohol.

5.

What Is the Primary Etiology of Psoriasis?

Psoriasis is caused due to immune system dysfunction where the skin cells are infiltrated by T-cells which stimulate keratinocyte proliferation. This causes the skin cells grow faster than usual, and this reaction may be triggered by various factors like weather, injury, infections, smoking, alcohol, or lithium medications.

6.

Which Are the Organs That Get Affected by Psoriasis?

Psoriasis hardens the skin and other connective tissues. The condition can affect the digestive tract, heart, lungs, and kidneys. Organs affected with psoriasis may degrade pathologically, and the person might develop conditions like psoriatic arthritis, Crohn’s disease, lung, cardiovascular, liver, and metabolic diseases, and some cancers as well.

7.

What Is the Consequence of Untreated Psoriasis?

Without treatment, psoriasis can lead to serious complications like psoriatic arthritis, diabetes, cardiovascular diseases, metabolic syndrome, anxiety, depression, inflammatory bowel disease, and kidney disorders.

8.

How to Diagnose Psoriasis?

Psoriasis is provisionally diagnosed by the primary physician who identifies the cutaneous symptoms. A skin biopsy followed by histopathological studies confirms the diagnosis and also detects the severity of the disease at a microscopic scale.

9.

How Effective Is Vaseline Against Psoriasis?

Vaseline is basically petroleum jelly, the application of which can manage psoriasis flare-ups. Petroleum jelly helps moisturize the skin, reduce itchiness, and manage scaly patches and cracked skin.

10.

How Serious Is Psoriasis?

Psoriasis is a rare condition that can be serious in certain forms like erythrodermic psoriasis, pustular psoriasis, or even progress to serious complications involving multiple organs.

11.

Does Psoriasis Last for an Entire Lifetime?

Due to the lack of a permanent cure, psoriasis lasts a lifetime. The patients need to continue management protocols throughout their life.

12.

What Is the Severe Form of Psoriasis?

Erythrodermic psoriasis is an extreme form of the condition where the lesions cover more than 90 % of the body’s surface area causing discoloration and skin shedding. This is a rare condition affecting less than 3 % of Americans and less than 3 % of all psoriasis cases.

13.

Who Is Susceptible to Psoriasis?

People carrying a dysfunctional immune system due to various causes, including infections, are prone to develop psoriasis. Caucasian populations hold a higher risk of developing the condition, followed by African Americans. Most commonly, psoriasis develops among age groups between 15 and 25.

14.

What Is the Genetic Cause of Psoriasis?

A single gene is not linked to psoriatic development. It is rather a mix of various genetic mutations and the onset triggered by various environmental, dietary, and lifestyle factors. Research states that genetic deletion of two EDC (epidermal differentiation complex) genes (LCE3B and LCE3C) has been strongly associated with psoriatic developments.

15.

How to Differentiate Psoriasis From Eczema?

Psoriasis is an autoimmune condition characterized by dry, thick, and itchy patches of the skin. At the same time, eczema is a chronic condition affecting the skin and is characterized by red, dry, and itchy rashes on the skin.
Dr. Suvash Sahu
Dr. Suvash Sahu

Dermatology

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