What is psoriasis?

Psoriasis is a recurrent skin condition that affects around 2% of the population in the UK. In simple terms, it is only an acceleration of the usual replacement processes of the skin. Normally a skin cell matures in 21 to 28 days during its passage to the surface where a constant invisible shedding of dead cells, as scales, takes place. Psoriatic cells, however, are believed to turn over in two to three days and in such profusion that even live cells reach the surface and accumulate with the dead cells in visible layers. Psoriasis affects both sexes equally. It may appear for the first time at any age, although it is more likely to appear between the ages of 11 and 45.

 What does it look like?

It appears as raised red patches of skin covered with silvery scales. It can occur on any part of the body although elbows, knees and the scalp are usual sites. There is often accompanying irritation. Some parts of the body do not have this typical scale. These are areas where two skin surfaces come together as in the natural skin creases and folds e.g. the groin and genital area and underneath women’s breasts. Psoriasis, in these areas can look bright red and shiny rather than scaly.

Is it catching?Most definitely not. Psoriasis cannot be caught from other people nor can it be transferred from one part of the body to another. How serious is it? Psoriasis is known as a waxing and waning condition and there may therefore be considerable variations in its intensity. There are also many clinical forms with skin involvement varying from a few psoriatic patches to, at its worst and very rarely, a widespread and serious eruption. Most people with psoriasis have small patches that either get better spontaneously or need very little treatment. The more severe forms may demand intensive medical and nursing care. Widespread ignorance about the nature of psoriasis and the real or imagined reactions of others may also lead to a withdrawal from society and to feelings of isolation, depression and defensive shyness.

What causes it? Certain genes have been identified as being linked to psoriasis. It appears, however, that a genetic tendency needs to be triggered off by such things as injury, throat infection, certain drugs and physical and emotional stress. Research is under way into all aspects of the causes of psoriasis.

What treatments are available?There are a variety of topical treatments available i.e. creams and ointments that are applied to the skin. When used properly they can be most effective and have minimal side effects. Whatever treatment you use it is also vitally important to use a moisturiser to make the skin more comfortable. Other treatments are available for more serious cases; they will normally mean a referral to a Dermatologist and involve treatment as an out-patient or in-patient. Many people, however, lose the condition naturally for long periods at a time or even entirely. It is important that you, as a patient should feel in control of your treatment regime and it is helpful therefore to talk it over properly with your GP, Consultant or Specialist Nurse.

What is psoriatic arthritis?

 Approximately 10% of people with psoriasis develop a specific type of psoriatic arthritis. This is an affliction of the joints particularly at the tips of fingers and toes and occasionally in the lumbar joints causing a low backache. Like psoriasis this form of arthritis can naturally wax and wane.

Children and psoriasis

Psoriasis is a recurrent skin condition that affects around 2% of the population in the UK. In simple terms, it is only an acceleration of the usual replacement processes of the skin. Normally a skin cell matures in 21 to 28 days during its passage to the surface where a constant invisible shedding of dead cells, as scales, takes place. Psoriatic cells, however, are believed to turn over in two to three days and in such profusion that even live cells reach the surface and accumulate with the dead cells in visible layers.

What does it look like?

It appears as raised red patches of skin covered with silvery scales. It can occur on any part of the body although elbows, knees and the scalp are usual sites. There is often accompanying irritation.

Is it catching? Most definitely not. Psoriasis cannot be caught from other people nor can it be transferred from one part of the body to another.

How does psoriasis affect children?Psoriasis is much less common in childhood than other skin problems such as eczema although around 10% of adults with psoriasis seem to have developed it before the age of 10. Guttate and scalp psoriasis are more common in childhood although many children will also have the usual distribution of plaques over the knees, elbow and lower back.

What is guttate psoriasis?  

The onset of psoriasis in children is often an outbreak of what is called guttate psoriasis. Gutta is the latin word for drop and this describes the small scaly patches affecting the trunk, limbs and occasionally the scalp. There may be a few rather larger patches or they may develop in time. This type of rash often follows an infection, often one caused by streptococci in the throat. Usually the rash clears well, although it can take several weeks or months, but in some children it can linger indefinitely. If a child has a tendency to tonsillitis the rash may come back with each attack.

Do babies get psoriasis? It is exceedingly rare for babies to have psoriasis particularly if there is no history in the family. Rashes in the nappy area may be psoriasis or may be a straightforward nappy rash. Psoriasis in the nappy area will look red and shiny and it will be very clearly demarcated i.e. it will be very obvious where the rash stops and normal skin takes over.

What causes psoriasis?Certain genes have been identified as being linked to psoriasis. It appears, however, that a genetic tendency needs to be triggered off by such things as injury, throat infection, certain drugs and physical and emotional stress. Research is beginning to unravel the genetic aspects and in time it should be possible to identify those who have a tendency to psoriasis before they actually develop signs. If one parent has psoriasis the chances of a child developing it is around 15%. However if both parents have psoriasis the chances increase to around 75%.

What treatments are available? Treatment must steer a course between doing too little and too much. Too little and worthwhile improvement is denied; too much and the life of the child and family is burdened by it. It is most important that parents talk through in detail the treatments proposed with the GP or Consultant. Many treatments in use for adults will help children but because of a lack of medical research on the effects on children some treatments are not licensed for use in childhood. It is important to follow instructions carefully and to keep the skin moisturised.

Immunisations

All the usual immunisation procedures may be safely given but it is worth remembering that a patch of psoriasis may come up at any site where the skin has been ‘injured’ e.g. following immunisation with BCG.Scalp psoriasis

Psoriasis is a common skin condition affecting 2-3% of the population of the United Kingdom and Ireland.What does it look like?

There is thick scale and redness that may also be obvious around the scalp margins, on the forehead, neck and behind the ears. . Many patients experience severe itching and a feeling of tightness and some report soreness. When should I go to the doctor?

For those with scalp patches which flare up from time to time it is possible to manage at home. Shampoo treatments are improving all the time and can be bought over the counter. Your pharmacist should be able to advise.
However if your scalp is covered with thick scale or it does not clear up do consult your GP who may arrange referral to a Dermatologist. There is a range of treatments which can be prescribed including coal tar, dithranol, salicylic acid, steroid creams and ointments as well as Vitamin D based treatments.Applying the treatment

The method of applying the treatment is most important. It involves parting the hair in sections and rubbing the treatment along the exposed areas. It is best to do this in order, working your way around the hair. You may need someone to help you in order to see the top of your head properly. You will find that some treatments need to be left on and some need to be washed out after a set period of time. Do follow the instructions that come with the product or the advice of your healthcare professional. Can I brush and comb?

Providing care is taken to avoid scratching the scalp, combing and brushing to remove scaling is not only good but necessary.What about perms and other hair treatments?

Scalp psoriasis should not prevent any cosmetic procedures. Having a perm or colouring the hair can have a positive effect on your self esteem. Hair dyes are gentler than they used to be but it would be best to seek advice from a hairdresser who should have up to date information about possible options, rather than colour or treat your hair at home. It is a good idea to make sure there are no scratches on the scalp when the hair is treated as the chemicals concerned can cause irritation on the broken skin.

I am embarrassed to go to the hairdresser

A good hairdresser should be able to help you manage your hair and scalp. Telephone in advance and speak to a stylist to explain the situation or try to find a hairdresser who will visit you at home. My hair is coming out!

Some people with severe psoriasis suffer temporary thinning of the hair. This can be very distressing but the hair will grow again once the flare-up has subsided.

Does it go away?

Psoriasis tends to come and go, and it can and does go away. Some people may be lucky enough not to suffer a further flare up. Others may experience long periods of remission. It is unusual for anyone to suffer extensive scalp psoriasis for a long time, provided they seek medical help and use treatments as directed. Helpful hints

• Brush and comb hair gently and regularly
• Buy some pillow case protectors or keep a supply of old pillow cases for times when you are using treatments
• Give all treatments a good chance to work - weeks rather than days
• Always read the instructions carefully on all treatments
• Tell your GP or Dermatologist if any treatment is causing you problems or discomfort
• Try different hairstyles to cover any psoriasis on the hairline
• Wearing light coloured clothes on the top half of your body will help to disguise falling scales
• Keep up to date with new treatments, the Association has details What is psoriatic arthritis?Psoriatic arthritis is a particular pattern of arthritis seen in association with psoriasis. There may be inflammation of one of several joints either in the hands, feet or larger joints or the spine. Typically only one set of joints is involved, although in rare cases it can become widespread. About 80% of those affected develop inflammation in their joints after the onset of psoriasis, but in about 20% the arthritis may be present before psoriasis. The joints affected may become tender, swollen and stiff. There is some evidence that inflammation of the tendons (tendonitis) without obvious inflammation of the joints (arthritis) may also be more common.

How does it differ from other forms of arthritis? In some cases it may mimic other forms of chronic arthritis and indeed having psoriasis does not preclude individuals from developing other forms of arthritis. However typically the pattern of joints that become inflamed is characteristic of psoriatic arthritis. For example if an entire finger or toe becomes swollen rather than an individual joint this is very suggestive of psoriatic arthritis. Other typical features may be involvement of the neck in those who suffer from the spinal form of arthritis or involvement of the very end joints of the fingers and toes.

Potentially any joint in the body can be involved but it is unheard of for all of them to become inflamed in any one individual. Usually only one set of joints is involved.

Is there any particular age of onset?

Psoriatic arthritis can develop at any age from early childhood and teenage years to later in life. Men and women are almost equally affected and there is some evidence that in females both following childbirth and during menopause there may be certain hormone related changes that trigger the onset of arthritis. It would seem also that men are more prone to developing arthritis of the spine and women more severe disease of other joints. How does the doctor diagnose psoriatic arthritis?

There is no specific test for psoriatic arthritis. Most doctors would look for a history of psoriasis in you or your family together with arthritis and inflammation in at least one joint. Blood tests for rheumatoid arthritis are usually negative although in some cases it is hard to distinguish between psoriatic arthritis and rheumatoid arthritis. Doctors will look for one of the familiar patterns seen in psoriatic arthritis as well as other clinical changes to make a final diagnosis.Nail pitting

Psoriatic nail disease is present in about 80% of those with psoriatic arthritis in contrast to about 30% of those with psoriasis alone. Examination of the nails therefore is most important.

What treatments are available?

There are many forms of treatment for psoriatic arthritis depending of course on the type and severity. Treatment may vary from rest and splints for acutely inflamed joints, physiotherapy with mobilisation and exercises for less actively inflamed joints to medications that can reduce inflammation. How can I help myself?

What is psoriasis? Psoriasis is a common skin condition affecting 2-3% of the population of the United Kingdom and Ireland.

What does it look like?Psoriasis appears as raised red patches of skin covered with silvery scales. It is very simply a speeding up of the usual replacement processes of the skin. This process is the same wherever psoriasis occurs on the body.

Psoriasis in sensitive areas Psoriasis can affect all parts of the body but there are some area where the skin is thinner and may be more sensitive to treatment. These areas include the flexures - in skin folds, armpits, under the breast, between the buttocks and the groin and genital area - as well as the face and hairline.
Psoriasis in sensitive areas may also be referred to as: -
• Genital psoriasis
• Flexural psoriasis
• Inverse psoriasis

How does psoriasis differ in a flexural area?Psoriasis in flexural areas often does not have the typical ‘plaques’ or scaliness seen in other areas and will appear as bright red, shiny patches of skin. It may be very uncomfortable and painful and may make people feel embarrassed about or avoid intimate situations.

It is not easy to pin pont what triggers psoriasis in flexural areas as it can just occur spontaneously. However, in the armpits and in the flexures and groin area psoriasis may sometimes worsen as a result of external factors. These may include tight clothing rubbing the skin, deodorants or antiperspirants, sanitary towels or tampons, harsh toilet paper, thrush and sexual intercourse. What should I do?

It is better to seek help from your GP or Dermatologist for flexural areas, as some products are more suitable for treating these areas than others.What treatments are available?

It is very important that you routinely use a moisturiser / emollient to make the skin more comfortable. In addition, there is a range of topical treatments available - creams and ointments - that your doctor can prescribe.
Skin in the flexural areas is thinner, and is often covered by clothing or even neighbouring skin such as the armpit. Treatment is absorbed more readily and therefore does not need to be as strong to be effective.
Topical Vitamin D creams and ointments can be very effective. The newer types are less likely to cause irritation, which has been a problem with these products in the past, making them more suitable for the treatment of sensitive areas and on the face. If you have widespread psoriasis it may now be possible to have just one treatment for all areas of the body.
Mild to moderate potency steroid creams may be recommended for flexural areas. However, care should be taken with their use in flexures as the warm, air-free environment can increase the potency and may lead to side effects such as skin thinning. It is also important that topical steroids are not used for long periods of time or without close supervision from your doctor. Treatments should never be stopped abruptly as this may trigger a rebound of your psoriasis.
Topical steroids may also be combined with anti-fungal and anti bacterial agents because infections with yeasts and bacteria are more common in sensitive areas. How can I help myself?

Psoriasis on the face and hairline

Psoriasis on the face is relatively uncommon and plaques may be less clearly defined, which sometimes leads to confusion with eczema.
If you have scalp psoriasis you may have specific treatments prescribed by your doctor that you can also use to treat psoriasis on your hairline. If these cause irritation on your facial skin, you should talk to your doctor about an alternative treatment that is approved for use on the face. Do use lots of moisturiser to help keep the scaling under control and to keep the skin comfortable. A weak topical steroid may help and there are Vitamin D based treatments which are licensed for use on the face.

Pustular Psoriasis It is somewhat confusing to have two types of psoriasis with similar names i.e. Generalised Pustular Psoriasis, which is quite a rare and serious form of psoriasis and, Pustular Psoriasis of the palms and soles (also referred to as palmoplantar pustulosis, PPP).

What is Pustular Psoriasis?
Pustular psoriasis of the palms and soles, also referred to as palmoplantar pustulosis, or PPP, is a chronic inflammatory skin condition where crops of sterile pustules (yellow pus spots) on the palms and soles of the feet erupt repeatedly over months or year. The affected areas become red and scaly, cracks may form and these are often painful. It has been thought to be a pustular variant of psoriasis.When pustular psoriasis is referred to without any further description, however, it usually means a much rarer and serious from of the disease where pustules are visible at other sites, this is often referred to as generalised pustular psoriasis or von Zumbusch pustular psoriasis. When pustules are visible in areas other than the palms and soles it very often means that psoriasis is in an unstable stage, and spreading very rapidly, this may make the patient feel quite ill from loss of heat and fluid resulting in feverish type symptoms.
In generalised pustular psoriasis the skin is covered with very small pustules on a background of very red, hot skin. This can develop quickly and so is essential to get medical help immediately.The fluid in the pustules is not an infection or bacteria, and the pustules are not contagious.

Causes of Pustular Psoriasis
As with other types of psoriasis, infections or stress may be a trigger factor in PPP. A strong association with smoking has also been identified, the mechanism of which is uncertain but may be linked to the products of smoking encouraging the inflammatory cells to accumulate in the epidermis (the top layer of the skin).
Generalised pustular psoriasis can be triggered by an infection, sudden withdrawal of topical or systemic steroids, pregnancy, and some prescription drugs.

Treatments
Topical treatments are normally prescribed first for PPP, in particular topical steroid creams and ointments. The doctor, nurse or dermatologist may advise the use of topical steroids under hydrocolloid occlusion (a type of dressing). Other forms of treatment that are used elsewhere can also be employed, i.e. tar, dithranol and bland emollients; salicylic acid is often incorporated into these preparations as it helps to reduce the thick scaling. PPP is typically stubborn to treat, should this be the case, the dermatologist may prescribe a course of PUVA therapy. PUVA therapy for the hands and feet may either involve oral psoralen or topical psoralen in which case it is applied like a paint – this is then followed by exposure to the ultra-violet A radiation. This modified PUVA treatment using a paint is especially useful for the feet; the patient sits with the soles exposed to a small UVA machine (as opposed to standing in a cabinet, where of course the soles are not reached by light).
A combination of PUVA with the oral retinoid Acitretin (RePUVA) has also been found to be effective for difficult to treat PPP, and is possibly more effective than the two treatments being used alone. Methotrexate and ciclosporin can also be used to treat PPP.
People with generalised pustular psoriasis often require hospitalisation for rehydration and topical and systemic treatments. These treatments typically include antibiotics and other systemic medications such as acitretin, ciclosporin or methotrexate. PUVA may be used once the severe stage of pustulosis and redness has passed. Age of onset
Pustular psoriasis of the hands and feet can occur at any age, but is rare in children and teenagers.
Generalised pustular psoriasis can also develop at any age, even occasionally in childhood, though it would be very rare at that time.

Acropustulosis (acrodermatitis continua of Hallopeau)
This rare type of pustular psoriasis is characterised by skin lesions on the ends of the fingers and sometimes on the toes. Often the lesions are painful and disabling, producing deformity of the nails. Occasionally, in severe cases, there may be bone changes.
The eruption may start after an injury to the skin, however studies investigating the cause of the disease have led scientists to believe that the staphylococcal infection plays a role.
Unfortunately, acrodermatitis continua of Hallopeau has been traditionally hard to treat. Initial treatment is with a steroid based ointment, often under occlusion. Oral drugs have been used with some success in clearing the lesions and restoring the nails. As with other forms of pustular psoriasis PUVA therapy may also be used.