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WHAT IS PSORIASIS?  FACTS AND TIPS

by Tony Pearce RN.
Specialist Trichologist, National Trichology Services

Psoriasis is reputedly the most common scaling problem seen by health professionals. The condition is a genetically determined autoimmune disorder believed to affect 2-5% of the world’s population.

With psoriasis the skin cells (epidermis) shed about seven times faster than the usual 28 days. Furthermore, the skin cells in unaffected people shed easily. By contrast, psoriatic skin cells are immature, sticky, and resist shedding. This results in scale formation on the skin surface.

The appearance of psoriasis varies from person to person; there may be heavy scale and redness in some whereas others have little of either. However the classic feature of psoriasis is a palpable bright pink plaque covered in silvery scale.

Although people who experience psoriasis have a genetic predisposition to develop it, it’s believed that it still takes something to trigger the problem. That could be a bacterial or viral infection, a vaccination/injection, stress, trauma to the skin or exposure to a substance not previously encountered.

Stress influences psoriasis through its effects on the Sympathetic Nervous System. Stress causes sympathetic nerves to increase their production of chemicals in the skin called neuropeptides. These neuropeptides can increase the autoimmune reaction in the skin.

Psoriasis is extremely variable in its duration and course. A single lesion may persist for a lifetime, or many lesions may be present. Some sufferers are never free of the problem whereas others may have long remissions. This same variation occurs in people’s response to treatment; what helps one person may not help another.

As psoriasis is believed to be an autoimmune condition, it can be suppressed but not presently cured. Remission may be spontaneous or induced, and last for weeks, months or years. Treatments are many, and help to control the condition in different ways:

• one therapy trichologists use for psoriasis involves the oral intake of the amino acid Tyrosine. Tyrosine decreases neuropeptides in the skin which, in turn, decreases the skin’s immune response. By doing this, the scaling and redness with psoriasis diminishes. Psoriasis should respond to this therapy within a month.

• Zinc sulphate 5% with 3% salicylic acid is a preparation used by some trichologists to relieve the symptoms of itch, redness and scaling.

• tar preparations are keratolytic, anti-inflammatory, and thought to be antimitotic. Coal tars can be compounded into ointments, creams, oils or shampoos. Often used in combination with salicylic acid for mild to moderate psoriasis.

• Anthralin(Dithranol) is extracted from coal tar and inhibits epidermal mitosis. Applied topically; anthralin irritates the skin and increases the immune response to that area. Anthralin should be applied to the scalp in “quarters”. Look for a reaction in first quarter before moving on.

• Daivonex(calcipotriol) is a non-steroidal vitamin D derivative.

• Roaccutane and Tigason are vitamin A derivatives

• severe chronic psoriasis may require treatment with potent oncological drugs such as methotrexate or cyclosporin. Oral or intravenously, these drugs can only be prescribed by a medical specialist and are generally only used when other treatments have failed. Regular monitoring of the patient’s white cell count and liver function are essential.

• ultraviolet light, PUVA, or judicious exposure to sunlight has proven beneficial to many psoriatics.

Topical Corticosteroids: topical steroids are anti-inflammatory and immunosuppressive. They can be very effective in controlling mild to moderate psoriatic lesions. Steroids are easy to use and offer a relatively quick response. Topical steroids are not considered adequate treatment when used as the only therapy for severe psoriasis. However they may augment other treatments that are used to treat severe psoriasis.

• There are several topical steroid medications specifically for use on the scalp. Some of these prescription products are: Cormax scalp application, Derma-Soothe/FS topical oil, Kenolog spray, and Temovate scalp application.

• Topical steroid medications don’t necessarily produce long remissions. Thus the early return of psoriasis can contribute to sufferers using steroids for long periods of time, or using a steroid that is too potent for a particular body area. This often heralds the appearance of common side effects associated with topical steroid use:

• Skin damage: skin atrophy, thinning of the skin, stretch marks(striae), steroid redness, and dilated inflammed surface blood vessels are possible side effects with the careless use of topical steroids.

• Rebound effect: as topical corticosteroids are essentially immunosuppressive, psoriasis tends to worsen if the steroids are discontinued suddenly. This is termed a psoriasis “rebound” or “flare”. This rebound effect may be stalled by slowly reducing or tapering the use of steroids as the psoriasis starts to remit. Some medicos prefer to gradually lower the strength of steroid medications to avoid rebound.

• Lack of Response (Tachyphylaxis) in long-term topical steroid use: changing from one steroid to another amy delay this effect, but the only way to prevent it is to temporarily cease using topical steroids. The substitution to non-steroidals such as Daivonex, Anthralin, tars or retinoids can be a useful interim alternative.

Psoriasis of the Scalp:
Psoriasis can affect any area of the skin but the scalp is a common site, where psoriasis tends to stay within the hairline. The crease of the ear is also often involved, and, sometimes scaling can be seen in the ears.

Where there are plaquey lesions, the scalp hair appears lustreless. The hair is dry and tends to break easily. There is an increased shedding of telogen(falling phase) hairs, and a decreased hair density. There may be extensive hair loss in the erythrodermic forms of psoriasis.

Heavy scale may cause hairs to be ‘funnelled’ together to form the distinguishing “tepee sign” of scalp psoriasis. Other characteristic features of psoriasis are ‘Auspitz’ sign’, where bleeding points are revealed beneath removed scale. ‘Koebner Phenomenon’ is where injury to the skin can induce the development of psoriatic lesions at the site of injury. It is believed the presence of large numbers of the yeast micro-organism, Pityrosporum ovale, amy be adequate to provoke a Koebner reaction in susceptible persons. Shampoos that are antipityrosporum-specific (eg: Nizoral 2%) have been advocated as an adjunct to therapy for scalp psoriasis.

Nail Psoriasis:
Nail involvement as an associated clinical sign or distinct entity is estimated to affect 50-80% of all people with psoriasis. When psoriasis affects the nails they can become deformed, which may distress and embarress the sufferer. Some common nail changes are:

• pitting of the nail surface: the number of pits is variable from one to dozens, and may leave the nail surface “thimble-like” in appearance. Although this can be upsetting, it does not alter the function of the nail.

• onycholysis: this is where the nail detachs from the underlying nail bed and a slight lifting of the nail occurs at the free edge. The lifting is usually seen as a yellowish patch that begins at the tip of the nail but may extend down to the cuticle. Onycholysis causes problems when the nail bed becomes infected, or debris gets caught under the lifting nail. This poses a particular problem for those who like to grow their nails long.

• sub-ungal hyperkeratosis: sub-ungal hyperkeratosis begins as an accumulation of chalky, scaling material beneath the nail. The nail may become raised up, and be tender when the nail surface is pressed. This is especially so with hyperkeratotic toe nails in the confinement of shoes.

• other less common changes are grooves and longitudinal ridging which may lead to a splitting of the nail. Reddish-brown spots under the nail are termed ‘splinter haemorrhages’, and are caused by the bursting of tiny capillary vessels under the nail.

The Treatment of Nail Problems: Because nails grow from the nail plate immediately under the cuticle, any treatment should be directed at the nail plate itself or, to the nail bed in the onycholytic nail. It is involvement of the nail plate that causes pitting and ridging in nail psoriasis. Onycholysis, sub-ungal hyperkeratosis and splinter haemorrhages are disease processes of the nail bed.

The current treatments are: vitamin D cream or ointment is considered the first-line treatment of choice. The preparation should be water-based not alcohol-based; this will avoid any stinging on application. The vitamin D should be massaged in to the cuticle for about 5 minutes, twice daily.

• nail removal can be quite painlessly achieved using a high concentration urea applied under polythene occlusion. The nail will become jelly-like and can be peeled off. Unfortunately nails tend to grow back abnormally.

• corticosteroid injections under the nail have shown some results in dermatology studies. Better results were noted in patients with sub-ungal hyperkeratosis than those with pitting or onycholysis. The major drawbacks with this therapy is that the injections can be extremely painful and may cause discomfort for a few days following. Furthermore, improvement is of a temporary nature only.

• nails should be kept clean and short. Any debris or scaling should be removed with a soft bristle brush.

Dietary Considerations:

• increase the amounts of fish eaten to 3-4 serves per week. ‘Oily fish’ such as salmon, sardines, tuna, herrings, kippers,etc. are best.

• increase green-leaf vegetable intake to approximately 1/3 of total dietary consumption for at least 5 days per week. Eat more foods that are high in naturally-occurring psoralen derivatives, eg: celery, carrots, figs, parsnips and fennel (a herb).

• drink at least 8 full glasses of filtered water per day. Black or green tea, preferably without milk, and caffeine/tannen-free. Avoid or minimise excessive coffee/alcohol consumption. Smoking also tends to aggravate psoriasis.

• consider evening primrose oil (epo) supplements; both women and men. Epo’s essential fatty acids help to maintain the structural integrity of cell membranes and cell metabolism.

• zinc supplements: zinc is essential to the maintenance of the immune system and normal T-cell functioning. It also plays a critical role in wound healing through collagen production. Zinc supplementation can interfere with iron absorbtion and copper levels so only take as prescribed.

• decrease red meat (substitute with legumes/chickpea or iron supplements).

• decrease crustaceans (prawns, crab, crayfish etc).

• decrease all spices.

• avoid smoking and alcohol.

• reduce soft-drink intake (especially artificially sweetened) and confectionary.

• experimenting with the diet can be useful as a food allergy, intolerance or food chemical sensitivity might be stirring up the immune system. The foods and substances most commonly implicated in sensitivity or allergic reactions are: dairy produce, wheat and grains, egg/egg products, preservative and colouring, shellfish, alcohol, tap water, cane sugar, peanuts.(is there anything left to eat you ask?!!!) When these foods or substances are consumed on a regular basis, problems can be quite difficult to identify because the symptoms they cause may be delayed or quite diverse. It is only when the offending foods(it may be one food or several) are excluded from the diet, that the body has time to recover properly. The ideal exclusion time for each food is 3 weeks. If a food sensitivity to that excluded food does in fact exist, then when it is re-introduced the symptoms will be more intense and so, easily identified. It is a good idea to maintain a diary, keeping track of foods eaten, foods challenged, and signs/symptoms which may arise.

And finally, “It’s worth a try...”

• add 1-2 cups of apple cider vinegar(acv) to a full bath of warm water and soak in it for 15-20 minutes twice daily. Acv(5% acidity) has been used since ancient times for the prevention and treatment of various health problems, especially skin conditions. For the psoriasis sufferer, an acv bath has been anecdotally shown to stop itch, clear light scaling and break-up heavier plaques.

• “old wives’ remedy” for a quick, economical and effective scale remover. Mix a thick paste of sodium bicarbonate powder and water. Liberally apply to lesion with a cotton wool swab in a gentle scour. Leave on 5-30 minutes, depending upon heaviness of scale. Shampoo out with usual products.

• Paw paw ointment is reputedly very effective for treating fingernail psoriasis and cracked, split skin around the nail bed. Paw paw ointment helps decrease scaling , and improves the overall appearance of the fingers. Apply 3 times daily and everytime handwashing is performed. Paw paw ointment is inexpensive and lasts well.

This paper is dedicated to Mr John Macfarlane, President of the Psoriasis Association of NSW Australia

“John, your tireless efforts on behalf of so many unknown to you can only be rewarded in heaven. Many thanks, and be kind to yourself.” TP.

Also read our Psoriasis Management article ‘Total Body’ Management of Psoriasis

About the Author: Tony Pearce is a Specialist Trichologist & Registered Nurse. He is a founding member of the Society for Progressive Trichology & the official lecturer for Analytical Reference Laboratory (ARL) for hair loss & hormone imbalance. He is the Clinical Director for Trichology of Virginia/DC in the United States. In Australia he can be contacted on 02 9542 2700, or through his website at www.hairlossclinic.com.au.

Copyright Anthony Pearce 2005. *References for this article available on request