Abstract
Psoriasis is a common skin condition that changes the life cycle of skin cells. Psoriasis causes cells to build up rapidly on the surface of the skin. The extra skin cells form thick, silvery scales and itchy, dry, red patches that are sometimes painful.
Psoriasis is a persistent, long-lasting (chronic) disease. There may be times when your psoriasis symptoms get better alternating with times your psoriasis worsens.
The primary goal of treatment is to stop the skin cells from growing so quickly. While there isn’t a cure, psoriasis treatments may offer significant relief. Lifestyle measures, such as using a nonprescription cortisone cream and exposing your skin to small amounts of natural sunlight, also may improve your psoriasis symptoms.
Symptoms
Psoriasis signs and symptoms can vary from person to person but may include one or more of the following:
- Red patches of skin covered with silvery scales
- Small scaling spots (commonly seen in children)
- Dry, cracked skin that may bleed
- Itching, burning or soreness
- Thickened, pitted or ridged nails
- Swollen and stiff joints
- Psoriasis patches can range from a few spots of dandruff-like scaling to major eruptions that cover large areas.
Most types of psoriasis go through cycles, flaring for a few weeks or months, then subsiding for a time or even going into complete remission.
Several types of psoriasis exist. These include:
Plaque psoriasis: The most common form, plaque psoriasis causes dry, raised, red skin lesions (plaques) covered with silvery scales. The plaques itch or may be painful and can occur anywhere on your body, including your genitals and the soft tissue inside your mouth. You may have just a few plaques or many.
Nail psoriasis: Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration. Psoriatic nails may become loose and separate from the nail bed (onycholysis). Severe cases may cause the nail to crumble.
Scalp psoriasis: Psoriasis on the scalp appears as red, itchy areas with silvery-white scales. The red or scaly areas often extend beyond the hairline. You may notice flakes of dead skin in your hair or on your shoulders, especially after scratching your scalp.
Guttate psoriasis: This primarily affects young adults and children. It’s usually triggered by a bacterial infection such as strep throat. It’s marked by small, water-drop-shaped sores on your trunk, arms, legs and scalp. The sores are covered by a fine scale and aren’t as thick as typical plaques are. You may have a single outbreak that goes away on its own, or you may have repeated episodes.
Inverse psoriasis.: Mainly affecting the skin in the armpits, in the groin, under the breasts and around the genitals, inverse psoriasis causes smooth patches of red, inflamed skin. It’s worsened by friction and sweating. Fungal infections may trigger this type of psoriasis.
Pustular psoriasis: This uncommon form of psoriasis can occur in widespread patches (generalized pustular psoriasis) or in smaller areas on your hands, feet or fingertips. It generally develops quickly, with pus-filled blisters appearing just hours after your skin becomes red and tender. The blisters may come and go frequently. Generalized pustular psoriasis can also cause fever, chills, severe itching and diarrhea.
Erythrodermic psoriasis: The least common type of psoriasis, erythrodermic psoriasis can cover your entire body with a red, peeling rash that can itch or burn intensely.
Psoriatic arthritis: In addition to inflamed, scaly skin, psoriatic arthritis causes pitted, discolored nails and the swollen, painful joints that are typical of arthritis. Symptoms range from mild to severe, and psoriatic arthritis can affect any joint. Although the disease usually isn’t as crippling as other forms of arthritis, it can cause stiffness and progressive joint damage that in the most serious cases may lead to permanent deformity.
AETIOPATHOGENESIS AND PATHOLOGY OF PSORIASIS
Environmental factors
Many factors besides stress have also been observed to trigger exacerbations, including cold, trauma, infections (eg, streptococcal, staphylococcal, human immunodeficiency virus), alcohol, and drugs (eg, iodides, steroid withdrawal, aspirin, lithium, beta-blockers, botulinum A, antimalarials). One study showed an increased incidence of psoriasis in patients with chronic gingivitis. Satisfactory treatment of the gingivitis led to improved control of the psoriasis but did not influence longterm incidence, highlighting the multifactorial and genetic influences of this disease. [8]
Hot weather, sunlight, and pregnancy may be beneficial, although the latter is not universal. Perceived stress can exacerbate psoriasis. Some authors suggest that psoriasis is a stress-related disease and offer findings of increased concentrations of neurotransmitters in psoriatic plaques.
GENETIC FACTORS
Twin studies have shown a higher concordance rate in monozygotic than in dyzygotic twins. In the recent years importance is given to the major human leucocyte histocompatibility antigens [HLA] that are located on chromosome 6. Patients with HLA-B17 have an earlier onset of disease than those with HLA-Bw16. HLA-Bw38 shows a strong association with distal psoriatic arthritis and HLA-B27 with generalized pustular psoriasis and psoriatic sacroilitis. In Indian psoriasis patients HLA-BW17 to be significantly associated with the disease. The HLA types most frequently reported to be associated with psoriasis are HLA-B13, HLA-B17, and HLA-Bw16.
PATHOLOGY
The cardinal pathophysiology is increase in epidermal proliferation. Psoriatic epidermis turns over 12 times faster than normal skin and there is two fold increases in uninvolved skin. In psoriasis the replacement of epidermis i.e. from basal cell to fully keratinized horny cell takes only 3 to 4 days unlike 27 days in normal course. As a result of this the horny layer is immature and parakeratotic, with nuclear fragments still present in the horn cell. It is this parakeratosis which is responsible for the silvery scaling and also the presence of air between the cells forming the scales, so characteristic of psoriasis. [NJH, 1995]
The epidermis basically consists of three cell compartments: a non-viable one consisting of the horny layer, a viable differentiated one consisting of stratum malpinghii and the stratum granulosum and the germinative cell compartment. Normally about 10% of the germinative cells undergo mitosis. The interval between the division of a basal cell and the next one of the daughter cell is called the cell cycle time.
The four stages in the cell cycle are:
1) Mitotic phase
2) G1 interphase
3) Synthetic Phase
4) G2 interphase
After mitosis the cell enters the G1 phase where a biochemical preparation for the next phase occurs. During the synthetic phase the DNA doubles. During the G2 phase a cell synthesizes RNA and proteins and prepares for the next mitosis. We don’t know the exact duration of the cell cycle in psoriasis. Studies by Weinstein and Frost revealed that the turnover time of the cells in psoriasis was reduced to 37 hours as compared to 457 hours for normal epidermis. Similarly early studies on the transit time of the cells from the basal cell layer to the upper most rows of the squamous cells showed a shortening from 13 days in normal epidermis to only 2 days in psoriatic epidermis. Having completed mitosis, the cells may remain in the cycle and recycle or may lose the capacity to divide, and recycle. If this occurs permanently, the cell becomes the post mitotic maturing basal cell which is destined for migration, differentiation, and eventual death and is lost in the horny layer.
The present view is that the cell cycle time of the germinative cells in psoriatic epidermis is about 100 hours as compared to 200 in the normal epidermis. The transition time of cells from basal cell layer to the upper most layers of squamous cells has now been calculated to be about 5 days rather than 2 days as was originally assumed.
The stratum granulosum is thinned or absent, and extensive overlying parakeratotic scale is seen. This typical thinning of the epidermal cell layer that overlies the tips of dermal papillae and dilated, tortuous blood vessels within these papillae. This constellation of changes results in abnormal proximity of dermal vessels within the dermal papillae to the overlying parakeratotic scale, and it accounts for the characteristic clinical phenomenon of multiple, minute, bleeding points when the scale is lifted from the plaque[Auspitz sign].There is usually a superficial, perivascular, lymphocytic infiltrate in psoriasis, the most diagnostically helpful inflammatory cells are neutrophils that form small aggregates within slightly spongiotic foci of superficial epidermis[spongiform pustules] and within the parakeratotic stratum corneum [Munro’s micro abscesses]. In pustular psoriasis, larger abscess like accumulations of neutrophils are present within the epidermis or directly beneath the stratum corneum.
PATHOGENESIS:
There is excessive but controlled cellular proliferation and inflammation within 0.2mm of skin’s surface. Pathogenesis is not understood clearly. Microscopically lesion is characterized by parakeratosis, absent granular layer, acanthosis and an inflammatory infiltrate in the dermis and epidermis. The role of immune mechanism is documented by activated T cells, by macrophages and certain class I HLA antigens. Secondly the predominant changes consist of highly increased, persistent keratinocyte proliferation in conjunction with a characteristic inflammatory pattern. It appears that several systems are involved in cuteneous repair and inflammatory defence mechanisms participate in establishing this disease.
In short the histopathological features of a fully developed psoriatic lesion are –
• Parakeratosis, which is usually uniform.
• Presence of ‘Munro’s micro abscesses’ in the horny layer. They consists of pyknotic nuclei of neutrophils that have migrated from the squirting papillae to the spongiform pustules and then to the horny layer.
• Absence of a granular layer.
• Regular elongation of rete ridges. Their lower portion is thickened, sometimes showing a camel foot like shape. Often they tend to coalesce.
Regular elongation of the dermal papillae that are clubbed at their upper portions. These are dilated and tortuous capillaries in the papillae with edema and perivascular mononuclear cell infiltration.
There is thinning of the suprapapillary parts of the stratum malpighi with the occasional presence of small spongiform pustules. In pustular psoriasis, these abscesses are large and prominent. Not all the above features are seen in each and every skin lesions of psoriasis. Spongiform pustules and Munro micro abscesses are the only features truly diagnostic of psoriasis.
Cell systems involved in Pathogenesis of Psoriasis:
There is a two-fold increase in proliferative cell population, and 100% of the germinative cells of the epidermis appear to enter the growth fraction, compared to 60-70% for normal subjects. These alterations result in a hyperplastic epidermis generating 35,000 cells/mm2 of skin surface. Normal skin produces only 1,218 cells/mm2. Additionally the regeneration response following tape stripping has been noted to be increased in the normal skin of patients with psoriasis. Probably as a result of these disturbances, changes in corneocytes have been described; more importantly increased size and increased cohesiveness. These changes may be directly responsible for the pathognomonic large scaling that is unique for psoriasis.
INFECTIONS:
Upper respiratory tract infections and tonsillitis when caused by streptococci may cause a flare-up of existing psoriasis or may precipitate an attack of acute guttate psoriasis seen more in children with an elevated ASO titre. Similarly Candida albicans, herpes, bacterial dermatitis can trigger it.
STRESS:
Psoriasis is more ‘stress sensitive’ than many other skin diseases. Many stressful events of daily life mayo exacerbate psoriasis. Disease itself can cause a reactive ‘depression’ in the patient which could further exacerbate t the psoriasis.In children the rate of stress related exacerbation may range as high as 90%. It is commonly believed that alcohol has an adverse effect on psoriasis, but this impression has not been confirmed.
Increased beta-endorthin in psoriatic skin might affect both substance P-mediated neurogenic inflammation and transmission of sensory stimuli by its local antinociceptive effects. Stress might induce alterations in the psoriatic lesion by increasing the neuropeptide content with a concomitant decrease in activity of neuropeptide degrading enzymes especially mast cell chymase.
DRUGS:
A papulosquamous eruption that may resemble psoriasis may be inducing by a number of drugs like beta adrenoreceptor blocking drugs, lithium, trazodone, chloroquine, Sodium valproate, Inderal and carbamazepine can also induce a psoriatiform eruption.
Risk factors
Anyone can develop psoriasis, but these factors can increase your risk of developing the disease:
Family history. Perhaps the most significant risk factor for psoriasis is having a family history of the disease. Having one parent with psoriasis increases your risk of getting the disease, and having two parents with psoriasis increases your risk even more.
Viral and bacterial infections. People with HIV are more likely to develop psoriasis than people with healthy immune systems are. Children and young adults with recurring infections, particularly strep throat, also may be at increased risk.
Stress. Because stress can impact your immune system, high stress levels may increase your risk of psoriasis.
Obesity. Excess weight increases the risk of psoriasis. Plaques associated with all types of psoriasis often develop in skin creases and folds.
Smoking. Smoking tobacco not only increases your risk of psoriasis but also may increase the severity of the disease. Smoking may also play a role in the initial development of the disease.
Complications
If you have psoriasis, you’re at greater risk of developing certain diseases. These include:
Psoriatic arthritis. This complication of psoriasis can cause joint damage and a loss of function in some joints, which can be debilitating.
Eye conditions. Certain eye disorders — such as conjunctivitis, blepharitis and uveitis — are more common in people with psoriasis.
Obesity. People with psoriasis, especially those with more severe disease, are more likely to be obese. It’s not clear how these diseases are linked, however. The inflammation linked to obesity may play a role in the development of psoriasis. Or it may be that people with psoriasis are more likely to gain weight, possibly because they’re less active because of their psoriasis.
Type 2 diabetes. The risk of type 2 diabetes is upped in people with psoriasis. The more severe the psoriasis, the greater the likelihood of type 2 diabetes.
High blood pressure. The odds of having high blood pressure are higher for people with psoriasis.
Cardiovascular disease. For people with psoriasis, the risk of heart attack is almost three times greater than for those without the disease. The risk of irregular heartbeats and stroke is also higher in those with psoriasis. This could be due to excess inflammation or to an increased risk of obesity and other risk factors for cardiovascular disease. Some psoriasis treatments may cause abnormal cholesterol levels and increase the risk of hardened arteries.
Metabolic syndrome. This is a cluster of conditions — including high blood pressure, elevated insulin levels and abnormal cholesterol levels — that increases your risk of heart disease. People with psoriasis have a higher risk of metabolic syndrome.
Other autoimmune diseases. Celiac disease, sclerosis and the inflammatory bowel disease called Crohn’s disease are more likely to strike people with psoriasis.
Parkinson’s disease. This chronic neurological condition is more likely to occur in people with psoriasis.
Kidney disease. Moderate to severe psoriasis has been linked to a higher risk of kidney disease.
Psoriasis can also affect your quality of life by increasing your risk of:
Low self-esteem
Depression
Social isolation
Problems at work, which can lead to a lower income
| DIETARY MANAGEMENT: |
| Avoid: • Avoid precipitating or trigger factors. • Avoid food you are allergic to. • Avoid smoking and alcohol. • Avoid foods high in fat or sugar. • Avoid non-vegetarian food – meat, poultry. |
| DO: |
| • Warmth may help to control relapses. • Do regular exercise helps by improving blood circulation. • Practice yoga will help in reducing stress. |
| CONSUME: |
| • Drink plenty of water. • Eat fresh and raw fruits and vegetables as they provide antioxidants and flavanoids which help in reducing inflammation and boosting up immunity. • Consume figs and fish oil might help you feel better. • Eat a well-balanced diet – Proper nutrition will improve general health and reduce the severity of the disease. Do not over eat even healthy foods. • Limit intake of red meat and dairy products. • Eat foods that contain psoralen before you walk out in sun – Celery, carrots, citrus, figs, fennel, and parsnips. It makes the skin more sun-sensitive to the positive effects of UV light. But do not over expose to sun. • Consume oily fish, may help reduce the inflammation associated with psoriasis – mackerel, salmon, black cod, albacore tuna, herring and sardines. • Have a low-calorie diet if you are over weight – about 1,200 calories per day. Some researches have shown relations between psoriasis and obesity. • Consume gluten free diet, it benefits individuals with psoriasis (Gluten is a mixture of proteins found in some cereals, particularly wheat) – avoid wheat, rye, barley and oats they contain gluten. • Increase intake of vitamin D. • Increase intake of omega 3 fatty acids and reduce intake of omega 6 fatty acids (ratio of 2:1), omega 3 fatty acid has anti-inflammatory properties. • Food rich in omega 3: – Canola oil, flaxseed, flax seed oil, walnuts and green leafy vegetables like purslane, fish – Atlantic salmon, Atlantic halibut, Atlantic mackerel, Atlantic and Pacific herring, sardines, bluefish, tuna and cold water fish. • Reduce (do not completely avoid) intake of food rich in omega 6: – Cereals, vegetable oils, whole-grain breads, baked goods and margarines, eggs and poultry. • Consume diet rich in vitamin A and zinc, helps in regeneration of the skin. • Increase intake of vitamin C, it helps maintain healthy skin. • Have coriander leaves frequently, its high in vitamin C and helps to maintain healthy skin. • You can have 3-4 strands of saffron in milk, it is beneficial for skin. • Basil leaves (tulsi) are said to be helpful in skin ailments, eat 3-4 fresh leaves daily. |
| CONSULT PHYSICIAN: If you suspect that you may have psoriasis, see your doctor for an examination. Also, talk to your doctor if your psoriasis: Progresses beyond the nuisance stage, causing you discomfort and pain Makes performing routine tasks difficult Causes you concern about the appearance of your skin Leads to joint problems, such as pain, swelling or inability to perform daily tasks Seek medical advice if your signs and symptoms worsen or don’t improve with treatment. You may need a different medication or a combination of treatments to manage the psoriasis. |
| • You can take vitamin and cod liver oil supplements under guidance of your physician. • In case of prolonged duration or change in rash pattern take physicians opinion immediately. • If symptoms get worse or if you see any Signs of infection (fever, redness of the affected area, pain) occur, see your physician immediately. |
Psoriasis is a chronic inflammatory skin disorder clinically characterized by erythematous, sharply demarcated papules and rounded plaques, covered by silvery micaceous scale. [Kasper Dennier, 2005].
The treatment of Psoriasis we have to understand not only pathology, disease progress of disease but also understanding Patient a whole. Homoeopathic system of medicine deal at the level of the fundamental cause i.e. at the level of susceptibility. The focus is on putting the system in order and hence the possibility of leading to cure.
Homoeopathy plays important role in managing the Psoriasis with proper judgment of disease condition along with proper understanding of miasms and susceptibility that denotes the prognosis of disease as well as selection of the potency and dose. Use of intercurrent remedy helps to remove the miasmatic blocks and helps for improvement for the complaints. And constitutional deep acting remedy will help to stimulate the system as a whole
Generally, the treatment of arthritis in psoriatic arthritis involves a combination of anti-inflammatory medications (NSAIDs) and exercise. If progressive inflammation and joint destruction occur despite NSAIDs treatment, more potent medications such as methotrexate (Rheumatrex, Trexall), corticosteroids, and antimalarial medications (such as hydroxychloroquine, or Plaquenil) are used.
Nonsteroidal anti-inflammatory drugs such as aspirin, indomethacin (Indocin), tolmetin.
Homeopathic Medicines of Psoriasis
(1)Arsenic Album – excellent psoriasis remedy in which psoriasis, worse by cold application and wetness, better by warmth.
(2)Kali Brom – remarkable psoriasis remedy in which there is syphilitic psoriasis. Skin cold, blue, spotted corrugated, large, indolent, painful pustules.
(3)Thyroidinum – one of the best psoriasis remedy for chilly and anemic subjects. Dry impoverished skin; cold hands and feet.
(4)Radium Brom – psoriasis of penis, itching eruptions on face oozing, Patchy erythema on forehead.
(5)Apis mellifica — for skin rashes that feel hot and dry and are sensitive to touch. Symptoms improve with cool baths and worsen with heat. This remedy is most appropriate for individuals who often feel sad, disappointed, or even depressed. They tend to cry easily but may also be irritable and envious by nature.
(6)Calendula –– used topically, particularly if the affected area becomes inflamed. This remedy will soothe but not cure the skin condition.
(7)Rhus toxicodendron — used for psoriatic arthritis and for skin disorders accompanied by intense itching that worsens at night and improves with the application of heat. This remedy is most appropriate for individuals who are generally restless and unable to get comfortable at night.
(8)Sulphur — for skin disorders that are accompanied by intense itching. This remedy is most appropriate for individuals who are thirsty, irritable when not feeling well, uninspired and messy under ordinary circumstances, and who describe a sensation of internal heat and burning. Symptoms tend to improve with open, cold air and worsen with warmth.
(9)Kali Arsenicosum– Kali Arsenicosum has marked action on skin disorders like eczema, psoriasis and ulcers. There is dry, scaly eruptions with itching worse from warmth, walking and undressing. It is also useful in chronic eczema. There are fissures in bends of arms and knees. There are numerous small nodules under the skin. Intolerable itching worse while undressing in psoriasis.
(10)Kali Sulphuricum– Kali Sulphuricum has marked action on psoriasis. There are burning, itching, papular eruptions. Skin is dry, hot and burning. Itchy eruptions in nettle rash in children. Kali Sulph also helps in seborrhoea or dandruff and ringworm of scalp or beard with abundant scales. Sores on skin with thick, profuse, yellow watery secretion.
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