Originally published in The Ottawa Citizen November 11, 2003
Original Title: Plaques are not trophies

October was National Psoriasis Awareness Month. Despite a press release from the Canadian Dermatological Association, the illness did not garner much press coverage.

Psoriasis fall into the category of common illnesses lost in the competitive din of common serious diseases. Two to five per cent of the world’s population suffers from this debilitating disease. Thirty-five percent of patients can identify a family history of the disease. A child with one parent with psoriasis can look forward to a 25 per cent chance of developing the disease and a 60 per cent chance if both parents suffer from it.

One million Canadians have psoriasis. It usually starts between the ages of ten to 40. Dr. Charles Lynde, dermatologist and president of the Canadian Dermatological Association states “Unless you are a patient suffering from the scaling, itching, pain and skin redness that characterizes psoriasis, the feelings of helplessness and frustration are hard to understand.”

Psoriasis is seen more often in alcoholics. Alcoholism is a significant risk factor for mortality among patients with psoriasis. The assumption is alcohol consumption may decrease the response to conventional treatment.

It has a variety of appearances and erupts on different body surfaces. It is an unpredictable illness that can flare for weeks to months followed by a period of quiescence.

Why does it occur? Normal surface skin cells shed every 28 days. Due to an immune system disturbance, the cells shedding time accelerates to every two or three days. This creates red, flaky itchy and often painful skin. The skin can become so severely cracked or split that secondary bacterial infections are a risk.

It has a major impact on the quality of life causing disabilities akin to diseases such as cancer and diabetes among others. Thirty per cent of psoriasis sufferers will have arthritic changes. Five to ten per cent will experience some degree of functional disability from arthritic change. The psychological effects include depression, low self-image and esteem, anxiety, feelings of hopelessness and suicide. Suicide rates are three times greater than the general population.

Psoriasis is a life-long disease. The areas of involvement include the knees, elbows, groin and genitals, back, arms, legs, palms and soles, face, scalp, body skin folds and nails. It is not contagious but requires vigilant follow-up to reduce and prevent the morbidity of relapses. The goal is to maintain a prolonged state of remission. Remission is seen in 25 per cent of patients.

Plaque psoriasis is a common form of the disease usually first appearing in young adults. Thick symmetrically distributed red plaques with sharp margins and white silvery scales appear on the arms, knees and scalp hair margin and range in size from one to ten centimeters.

A variant (flexural variant) appears in the armpits and under the breasts. These plaques are smooth, red and shiny.

Guttate psoriasis occurs in adolescents and adults. It appears as one centimeter “drop-like” lesions symmetrically distributed on the trunk and limbs.

Several localized forms appear on the palms and scalp. Palmoplantar psoriasis is characterized by the appearance of yellow to brown coloured sterile pustules on the palms of the hands or soles of the feet. It is commonly seen in middle aged females with a cigarette smoking history.

For some, scalp involvement is the disease’s only manifestation.

Nail changes occur in 50 per cent of psoriasis cases. Small pits and crumbling of the nail’s edge are common. A tan-brown motor oil-like discolouration appears in the nail (the “oil drop sign).

Certain medications will make psoriasis worse: beta blockers, lithium, and antimalarial drugs; angiotensin converting enzyme inhibitors (ACE) and non steroidal anti-inflammatory drugs (NSAIDs).

Other complications include arthritis of the hands and feet causing sausage-like swelling of the finger or toes joints (distal interphalangeal) adjacent to the nails, rheumatoid-like arthritic changes, erosion of the small bones of the hands and feet (mutilans arthritis) and ankylosing spondylitis/sacroiliitis.

The basis for the choice of treatment depends upon the severity of the illness. Mild plaque psoriasis can be treated with topical corticosteroids and emollients. Two newer treatments are available. Dovobet (a topical steroid with the vitamin D derivative calcipotriol) and Tazorac (tazarotene, a vitamin A derivative) are effective in mild to moderate psoriasis. Improvement occurs within one to four weeks.

Other options for moderate plaque psoriasis include potent topical steroids with or without tar and ultraviolet phototherapy. Widespread psoriasis requires phototherapy or more specialized systemic therapies best handled by dermatologists.

All these treatments continue to be refined and optimized to help more people with psoriasis live a normal life. Please consult your doctor to review the treatment that is best for you.

Further information is available at http://www.dermatology.ca and http://www.skincarephysicians.com/psoriasisnet/whatis.htm

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© Dr. Barry Dworkin 2003