Psoriasis Treatment

Psoriasis is a chronic immune-mediated inflammatory skin disorder with a strong genetic predisposition. It is characterized by hyperproliferation of keratinocytes, leading to thickened, scaly plaques on the skin.

The disease follows a chronic relapsing and remitting course and may significantly affect quality of life. It is not contagious.

Psoriasis may also involve:

• Nails

• Joints (psoriatic arthritis)

• Scalp

Epidemiology

• Affects 1–3% of the global population

• Can occur at any age

• Peaks at 20–30 years and 50–60 years

• Family history common

Etiology and Risk Factors

Psoriasis is multifactorial:

Genetic predisposition

• Strong familial association

Triggering factors

• Stress

• Alcohol

• Smoking

• Infections (especially streptococcal throat infection)

• Trauma to skin (Koebner phenomenon)

• Drugs (beta-blockers, lithium, antimalarials)

• Deficiencies of vitamin B12 or folate

Pathophysiology

• Immune system dysregulation involving T-cells

• Overproduction of inflammatory cytokines (TNF-alpha, IL-17, IL-23)

• Rapid epidermal turnover (3–5 days instead of 28 days)

• Accumulation of immature keratinocytes → scaling plaques

Clinical Types

Plaque Psoriasis (most common)

• Thick silvery white scaly plaques

• Extensor surfaces and scalp

Guttate Psoriasis

• Small drop-like lesions

• Often after streptococcal infection

Pustular Psoriasis

• Sterile pustules

Erythrodermic Psoriasis

• Generalized redness and scaling

• Medical emergency

Nail psoriasis

• Pitting

• Onycholysis

• Subungual hyperkeratosis

Psoriatic arthritis

• Joint pain and stiffness

Signs & Symptoms

• Thick, silvery white scaly plaques

• Well-demarcated erythematous base

• Common sites:

  • Scalp

  • Sacral region

  • Extensor surfaces (elbows, knees)

• Symmetrical distribution

• Chronic relapsing course

• Itching (variable severity)

Diagnostic criteria

Clinical diagnosis based on:

• Well-demarcated erythematous plaques

• Silvery white scales

• Symmetrical distribution

• Chronic relapsing pattern

Supportive clinical signs:

• Auspitz sign (pinpoint bleeding when scales removed)

• Koebner phenomenon

Always exclude precipitating factors such as alcohol use, infections, stress, and vitamin deficiencies.

Investigations

Usually clinical diagnosis.

If needed:

• Skin biopsy (acanthosis, parakeratosis)

• Full blood count

• ESR or CRP (if arthritis suspected)

• Vitamin B12 and folate levels

• Throat swab (guttate type)

• Liver and renal function tests before systemic therapy

Treatment

Treatment depends on severity and extent.

Non-Pharmacological Treatment

• Sun exposure to lesions (30–60 minutes daily)

• Avoid alcohol and smoking

• Stress reduction

• Weight control

• Regular moisturization

• Avoid skin trauma

Pharmacological Treatment

Topical therapy (Mild to moderate disease)

Morning

• Crude coal tar 5% in Vaseline — apply once daily in the morning for not less than 3 months

AND

Night

• Salicylic acid 5% in Vaseline — apply once daily at night for not less than 3 months (for de-scaling)

AND

Every 12 hours

• Betamethasone valerate ointment (topical) 0.25% — apply every 12 hours for not less than 12 weeks

OR

• Betamethasone dipropionate + salicylic acid ointment (topical) — apply every 12 hours for not less than 4 months

Severe disease

• Clobetasol propionate cream/ointment (topical) 0.05% — apply every 12 hours for not less than 4 months

Extensive disease

For extensive involvement (>20% body surface area) with joint involvement

ADD

• Methotrexate (PO) 7.5–20 mg once weekly for not less than 6 months

Important Note

• Systemic corticosteroids should not be used in psoriasis because of their rebound effect, which may cause severe worsening of the disease after discontinuation.

Moderate to Severe Disease

If poor response, refer to higher-level facility for:

• Methotrexate

• Cyclosporine

• Azathioprine

• Phototherapy

• Biologic therapy (specialist setting)

Systemic corticosteroids are discouraged due to severe rebound flare.

Complications

• Psoriatic arthritis

• Erythroderma

• Nail deformity

• Cardiovascular risk increase

• Depression and anxiety

Prognosis

• Chronic lifelong condition

• Periods of remission and relapse

• Early treatment improves outcomes

Prevention

• Avoid triggering factors

• Treat infections early

• Maintain healthy lifestyle

• Adherence to treatment

• Regular follow-up