Psoriasis

Diagnosis  

The dermatologist uses the following procedure to aid in diagnosing psoriasis: 

• Physical examination: The healthcare provider will inquire about the patient’s health, ask about family history, and assess the skin, scalp, and nails.  
• Biopsy: A skin biopsy test may be recommended by the healthcare provider to confirm the diagnosis of psoriasis since the presence of a skin plaque indicates the disorder, but symptoms can also be related to other similar skin conditions. A small sample of skin tissue from the skin plaque will be taken during this examination, and the healthcare provider will analyze it under a microscope.  

Treatment  

Psoriasis treatments aim to slow down the rapid growth of skin cells and eliminate scales, offering various options such as topical therapy (creams and ointments), phototherapy (light therapy), and oral or injected medications. The choice of treatment depends on the severity of the psoriasis and its response to previous therapies and self–care efforts. Often, a trial of different drugs or a combination of treatments is necessary before finding an effective approach. However, even with successful treatment, the disease typically recurs over time. 

Topical therapy 

• Corticosteroids: The most commonly prescribed medications for mild to moderate psoriasis are topical corticosteroids, available in various forms like oils, ointments, creams, lotions, gels, foams, sprays, and shampoos. For sensitive areas like the face or skin folds, and for widespread patches, mild corticosteroid ointments like hydrocortisone are recommended. During flares, topical corticosteroids can be applied once daily, while during remission, they can be used on alternate days or weekends. In cases where smaller, less sensitive, or stubborn areas require treatment, stronger corticosteroid creams or ointments such as triamcinolone or clobetasol may be prescribed. It’s important to avoid long–term or excessive use of potent corticosteroids as they can lead to skin thinning and potential loss of effectiveness over time. 
• Vitamin D analogue: Vitamin D synthetic derivatives, like calcipotriene and calcitriol, are effective in slowing down skin cell growth. They can be used either on their own or in combination with topical corticosteroids. Calcitriol is particularly suitable for sensitive areas as it causes less irritation. However, it’s worth noting that these vitamin D derivatives are generally more expensive compared to topical corticosteroids. 
• Retinoids: Tazarotene is available in the form of a gel or cream, and it is typically applied once or twice daily. However, its usage is associated with some common side effects, including skin irritation and increased sensitivity to light. For individuals who are pregnant, breastfeeding, or planning to conceive, it is not recommended to use tazarotene due to potential risks. 
• Calcineurin inhibitor: Calcineurin inhibitors, like tacrolimus and pimecrolimus, are effective in soothing rashes and reducing scaly buildup. They are particularly beneficial in areas with thin skin, such as around the eyes, where the use of steroid creams or retinoids might cause irritation or harm. However, it’s important to note that these inhibitors are not recommended during pregnancy, breastfeeding, or if there are plans to conceive due to potential risks. Additionally, their long–term use should be avoided as it may be associated with an increased risk of skin cancer and lymphoma. 
• Salicylic acid: Shampoos and scalp treatments containing salicylic acid lessen the scaling caused by scalp psoriasis. Both non–prescription and prescription strengths are offered. This kind of substance makes the scalp more receptive to drug absorption, therefore it can be used alone or in conjunction with other topical therapies.  
• Coal tar: Scaling, irritation, and inflammation are all reduced by coal tar. Both nonprescription and prescription strengths are offered. It is available in several forms, including shampoo, cream, and oil. These goods could irritate your skin. They can also have a strong stench and are untidy, staining clothing and bedding. When you are expecting or nursing, you shouldn’t have coal tar therapy.  
• Anthralin: Skin cell development is slowed down by the tar cream anthralin. Scales and rough skin can both be removed by it. Use on the face or genitalia is not recommended. Anthralin may make skin irritated and stains nearly everything it comes in contact with. Typically, it is administered for a brief while before being removed with water.  

Light therapy

Light therapy is commonly used as a first–line treatment for moderate to severe psoriasis, either alone or in combination with medications. The process involves controlled exposure of the skin to natural or artificial light. It’s important to have repeated treatments to achieve desired results. If you’re considering home phototherapy, consult your healthcare provider to determine if it’s suitable for you. 

Different types of light therapy options are available: 

• Sunlight (heliotherapy): Which involves brief daily exposures to sunlight, has the potential to improve psoriasis. However, before initiating a sunlight regimen, it is essential to consult your healthcare provider to ensure the safest and most effective way to use natural light for treating psoriasis. 
• Goeckerman therapy: This approach combines coal tar treatment with light therapy, as coal tar enhances the skin’s response to ultraviolet B (UVB) light, making it more effective.
• UVB broadband: UVB broadband light therapy from an artificial light source is a suitable treatment for single psoriasis patches, widespread psoriasis, and cases where topical treatments have not shown improvement. Nonetheless, there might be short-term side effects like inflamed, itchy, and dry skin.
• UVB narrowband: UVB narrowband light therapy is often considered more effective than UVB broadband treatment and has replaced broadband therapy in many locations. Typically, it is administered two or three times a week until the skin improves, and then less frequently for maintenance therapy. However, it is important to note that narrowband UVB phototherapy may lead to more severe side effects compared to UVB broadband treatment.
• Psoralen plus ultraviolet A (PUVA): This treatment entails administering a light–sensitizing medication (psoralen) to the patient prior to exposing the affected skin to UVA light. UVA light has superior skin penetration compared to UVB light, and psoralen enhances the skin’s responsiveness to UVA exposure. This more potent approach is commonly employed for severe psoriasis cases and consistently yields improved skin outcomes. However, short–term side effects like nausea, headaches, burning, and itching may occur. Potential long–term effects encompass dry and wrinkled skin, freckles, heightened sun sensitivity, and an increased risk of skin cancer, including melanoma. 
• Excimer laser: This form of light therapy involves the targeted application of strong UVB light exclusively to the affected skin. In contrast, excimer laser therapy necessitates fewer sessions than traditional phototherapy as it employs a more powerful UVB light. Potential side effects of this treatment may include inflammation and blistering. 

Medication 

For moderate to severe psoriasis cases, or when other treatments have been ineffective, healthcare providers may prescribe oral or injected (systemic) medications. Some of these drugs may only be used for short periods and could be alternated with other treatments due to the potential for severe side effects. 

• Steroids: Injections of corticosteroids may be used for a few small, persistent psoriasis patches. 
• Retinoids: Pills such as acitretin and other retinoids may be prescribed to reduce the production of skin cells. Side effects may include dry skin and muscle soreness. These drugs are not recommended during pregnancy, breastfeeding, or if planning to become pregnant. 
• Biologics: These drugs, typically administered by injection, modify the immune system to disrupt the disease cycle and improve symptoms within weeks. They are approved for treating moderate to severe psoriasis in individuals who haven’t responded to initial therapies. Some options include apremilast, etanercept, infliximab, adalimumab, ustekinumab, secukinumab, ixekizumab, guselkumab, tildrakizumab, and certolizumab. Etanercept, ixekizumab, and ustekinumab are approved for use in children. These drugs can be costly and may or may not be covered by health insurance plans. Biologics require caution as they can suppress the immune system, increasing the risk of serious infections. People taking these treatments should be screened for tuberculosis. 
• Methotrexate: Usually taken orally once a week, methotrexate reduces the production of skin cells and suppresses inflammation. It’s less effective than some biologics but may cause upset stomach, loss of appetite, and fatigue. Regular blood count and liver function testing are necessary for those taking methotrexate long–term. People planning to conceive should stop using this drug at least three months before attempting pregnancy. It is not recommended during breastfeeding. 
• Cyclosporine: Taken orally for severe psoriasis, cyclosporine suppresses the immune system. It’s similar in effectiveness to methotrexate but should not be used continuously for more than a year. Like other immunosuppressants, cyclosporine increases the risk of infection and other health problems, including cancer. Regular blood pressure and kidney function monitoring are necessary for long–term use. This drug is not recommended during pregnancy, breastfeeding, or if planning to become pregnant. 
• Other medications: In certain situations where other drugs cannot be used, medications like thioguanine and hydroxyurea might be considered. It’s important to discuss possible side effects of these drugs with your healthcare provider.