Psoriasis is a chronic, inheritable, noncontagious skin disorder. Plaque psoriasis is the most common type, with red raised plaques and silvery scale. It is most frequently found on the scalp, elbows, knees, and lower back. Itching and burning are  common symptoms. A less common variant, pustular psoriasis, usually presents as pustules on the hands or feet but can involve the entire body. When psoriasis involves the entire body, the condition is termed “erythrodermic psoriasis”. This can be a dermatologic emergency with patients experiencing high fevers, dehydration, and protein deficiency due to loss of skin scales. Occasionally, psoriasis involves skin folds (underarms, groin creases etc.) and is termed inverse psoriasis. Psoriasis limited to the scalp is termed seborrheic dermatitis. Guttate psoriasis presents as myriad tear-drop size papules, often following a strep throat infection. Psoriasis can also cause pitted nail plates or thickened crumbly nails with or without skin lesions (not all thickened yellow nails are caused by a fungus!). Furthermore, psoriasis can involve the joints, resulting in a destructive arthritis similar to Rheumatoid Arthritis.

What causes Psoriasis?

Over 7 million people in the United States are affected with this skin disorder and approximately 150,000 new cases are reported each year. The cause is unknown, though it is accepted  as a genetic disease, inheritable from a parent or relative.   One in three patients report a family history of psoriasis.   Scientists believe that people with psoriasis have a limited immune system abnormality that leads to skin inflammation (redness, itching, pustules) and also an increase in the cell division rate of the epidermis (the epidermis being the top layer of the skin). Recent discoveries point to an abnormality in the functioning of special white cells (T-Cells) which trigger inflammation and the immune response in the skin. Because of the inflammation, the skin grows too rapidly.  It normally takes 4 to 6 weeks for new cells to form and reach the top layer of the skin.  A patient with psoriasis has skin cells that multiply so fast they can reach the epidermal surface in 7 days.   Perhaps due to their rapid transit through the epidermis, psoriatic skin cells never form a normal skin surface.  They pile on top of each other leading to the formation of thick scaly plaques.

What is the treatment for Psoriasis?

Treatment plans for psoriasis patients at our clinic are individualized and formulated based on the following factors:  type of psoriasis, extent and severity, body locations, and the patient’s medical history, lifestyle, and age.  Our goal is to reduce inflammation and slow down the abnormally rapid epidermal growth rate.  Various treatment levels are available ranging from mild topical medications with limited side effects to powerful systemic drugs.

Level 1:  Topical Medications

The first level of treatment involves the application of medications directly to the skin.  This level of treatment is most practical for mild to moderate psoriasis.  Topical Steroids are the most topical common therapy prescribed.  Glucocorticoid  steroids are primarily anti-inflammatory and can promptly reduce redness and itching as well as slowing down the growth rate of involved skin.  Various strengths, ranging from mild to super potent, can be prescribed. Side effects are rare with appropriate use but include thinned skin, stretch marks and acne.  Superpotent steroids can suppress natural hydrocortisone production.  With prolonged use, steroids also tend to lose their effectiveness.  For these reasons, we choose the strongest appropriate steroid and monitor for rapid response so the steroid cream can also be stopped.  Also, oral steroids are never used in psoriasis due to the risk of a rebound flare. Sometimes lesions can be injected with steroids if only a few small lesions exist.  Topical Vitamin  D (Calcipotriene) is also effective as a topical medication along with Topical Vitamin A ( Tazorac), which is a retinoid compound.  Both medications work primarily by reducing the production of new skin cells.   While they tend to be slower in onset than topical steroids, they do not thin the skin or lose their effectiveness with prolonged use.

Level 2:  Photochemotherapy

Natural sunlight has been used to treat psoriasis for decades.  Certain wavelengths of ultraviolet light (UV) have also been proven effective.  These selected spectrums of light are termed short-wavelength UV (UVB) and long wavelength (UVA).  UVA is ineffective without the concomitant use of a medication called 8-methoxypsoralen (8-MOP), also called Oxsoralen Ultra.  That is why tanning beds, which emit primarily UVA, are a poor treatment for psoriasis.  The use of 8-MOP and UVA light is called PUVA and we have found this to be a very effective tool for inducing a remission of  psoriasis.   

Photochemotherapy (PUVA)  is one of the only treatments that can induce a remission of psoriasis.  We also have a new generation UVB device that only generates a narrow band of UVB.  This treatment, only recently imported from Europe, avoids potential complications of  8-MOP, and in some studies has equal efficacy as PUVA.  By using only a narrow band rather than a full band of UVB, unnecessary UV exposure is eliminated.  Though excessive UV light can cause photoaging  and skin cancer, medically supervised administration of ultraviolet light is very safe and effective to control widespread or stubborn, unmanageable psoriatic lesions.

Level  3:  Internal Medications

We tend to prescribe oral medications for severe cases of psoriasis that have been non-responsive to other treatment modalities.  Patients are closely monitored to achieve the highest therapeutic response while minimizing  potential side effects.  Methotrexate  is an oral anti-cancer drug that can produce dramatic clearing of psoriasis by slowing down skin cell growth.  Acetritin is an oral retinoid that slows down epidermal cell rate division and is used for plaque-like psoriasis. However, Acetritin has many annoying side effects such as dryness, hair loss, and can cause birth defects. Cyclosporine is an immunosuppressant  medicine that can dramatically reduce the  inflammation within  psoriatic lesions. Cyclosporine has one of the fastest treatment response-times of any drug for psoriasis and is especially useful for erythrodermic psoriasis.  Unfortunately, all theses treatments have serious potential side effects, require intensive clinical and laboratory monitoring, and  are expensive.  Patients are closely monitored as we follow a rotational protocol and change these therapies every 6 to 12 months.

Level 4:  Xtrac Laser

The X-TRAC laser has been utilized at the Olympic Dermatology and Laser Clinic since 2002.  The X-TRAC excimer laser is indicated for individuals with mild to moderate psoriasis and who often can obtain relief in just 4 to 10 treatments sessions. The X-TRAC excimer laser system uses a carefully focused beam of light delivered thru a sophisticated liquid light guide to quickly and effectively treat unsightly psoriatic skin plaques.  Because it is a concentrated beam of light, the X-TRACT laser delivers high exposure doses necessary for rapid clearing without risk of damage to healthy skin. 
 
Psoriasis patients receiving X-TRAC treatments  have found that relief usually lasts for 2 to 6 months.  Often remissions can last as long as conventional Phototherapy, but less treatments are necessary per year to remain free of symptoms.

Level 5:  Biomodulation

Researchers have bioengineered new medications that can be delivered to a specific target in a skin cell to turn off rapid skin cell production.  Listed below are several of the new biologic agents that are presently being used at Olympic Dermatology and Laser Clinic:

Alefacept (Amavive)— This is a biologic agent that works by blocking the over activation of T-Cells. Alefacept is for moderate to severe chronic plaque psoriasis and is administered through an injection.

Etanercept (Embrele)— This is a biologic agent that blocks tumor necrosis factor-alpha (TNF-), thereby interfering with a key cytokine that contributes to the development of psoriasis. It has been used for psoriatic arthritis and also benefits cutaneous psoriasis.   There are other Biologic Agents that are presently being researched and  used including Infliximab, Adalimumab and Efalizumab.  These drugs can blocks activation of T-Cells and the movement “trafficking” of T-Cells into inflamed skin, thus improving psoriasis.
Great progress has been made over the last 10 years in understanding psoriasis.  New promising immunosuppressant medications that are 10 to 100 times stronger than cyclosporine are also  being studied to determine their effectiveness on slowing down the immune system.  Genetic DNA research is also being pursued to possibly develop specific gene therapies for patients diagnosed with psoriasis.  It is an exciting new era for the research and medical management of psoriasis.  As a Psoriasis Treatment Center our goal is to keep you informed of new developments and provide expertise and advanced treatment options for your care.

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