This chronic skin disease affects 2 to 3% of the French population. Hence we found out the necessity to present symptoms and treatment of psoriasis. There is a genetic component: one-third of patients have a family history. So what are the symptoms of psoriasis? What treatments for psoriasis?

Whatever the age, one can suffer from psoriasis. The immune system is racing and the cells of the skin hyperproliferate. It does not matter, but it lasts. Red patches are formed with, in the center, characteristic whitish scales, small dead skin that peel off and fall.

Symptoms and Treatment of PsoriasisSymptoms and Treatment of Psoriasis

I – Symptoms of Psoriasis

Psoriasis can have many aspects.

Whatever its form, we find the plaque characteristic of psoriasis: it is rounded with very sharp contours, covered with large scales (slats of dead skin) thick, white, that can be scratched with the nail, making him start with a whiter shade, this is called the “candle spot”.

If all the scales are removed, the bright red plaque that forms the base of the psoriasis plaque is obtained.

It can cause itchiness that is difficult to control.

In addition to the most traditional locations such as elbows, knees, the base of the back and the scalp, psoriasis is often placed on the front of the leg, on the palms of the hands and the soles of the feet, at the navel , nails and on the genitals (especially in humans).

Its extent is very variable. Sometimes it may consist of an eruption, very rapid onset, with small elements, which is called “psoriasis drops”.

In other cases, it can be expressed by large plates, rounded, very large, sometimes with a somewhat ring-shaped appearance.

Less common, but more serious to their extent, some psoriasis can affect the whole body.

Rare forms of the disease differ from the usual “plaque” psoriasis by their pustular character: the surface of the plaques has small, whitish pustules that are not contagious.

This aspect is found especially on the palms of the hands and soles of the feet, in the form of “pustular palmar-plantar psoriasis”.

Even more rarely, more severe forms of psoriasis can take on a generalized pustular appearance.

*** Aspects of Psoriasis

The appearance may be different depending on the location

– On the palms of the hands and the soles of the feet, psoriasis is often manifested by a thickening of the whole epidermis which appears dry, desquamative, aggravated by manual labor, which makes it mistaken for eczema of contact.

This is where we often meet the “pustular” forms.

– At the level of the nail, where the location is very frequent, manifested either by small depressions in “thimbles” on its surface or by the bulk lifting of the nail by a large thickness of scales. The involvement of the nails is often chronic.

– Psoriasis of the scalp is a very troublesome localization requiring frequent local treatments to avoid significant thickening of the psoriasis plaques.

The entire scalp can be reached and the plates often overflow the edge of the scalp. Psoriasis does not make the hair fall, however, neglected psoriasis, with thick crusts on the scalp, is obviously an obstacle to hair growth.

– On the face, the plates are very troublesome but are less frequent, except in children. Sometimes, they settle on the wings of the nose and above the eyebrows, taking the appearance of seborrheic dermatitis, inflammation of the skin very common in the central areas of the face.

Psoriasis can also reach the folds, including the intergluteal fold, underarm, groin folds, giving bright red patches, well limited, symmetrical, which are sometimes confused with fungal infections.

This location is particularly chronic.

No place is spared by psoriasis, even the mucous membranes, since they are often met with on the mucous membrane of the glans in men, in the form of red patches, again frequently confused with other affections.

 

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II – Diagnosis of Psoriasis

The type of lesions and their location make it possible to make the diagnosis?

The diagnosis of plaque psoriasis of the adult is made by the doctor after a consultation which highlights red and squamous lesions (erythemato-squamous) well limited, most often symmetrical touching preferentially the elbows, the knees, the loins, and scalp. These lesions evolve by thrusts with or without complete remission between relapses. It is not necessary to carry out additional examinations.

At this stage, it is very important to take stock of the importance of psoriasis because the proposed treatment will depend on it. The repercussion is obviously subjective but it is based on:

– the extent of the lesions and their more or less disabling side

– resistance to treatment

– and especially the harm felt in aesthetic, relational, professional and of course personal for his own psychological balance.

III – Treatments for Psoriasis

Psoriasis is manifested by red and scaly patches on the hands, elbows, knees … This disease is not contagious but remains discriminant. Corticosteroids, immunomodulators, phototherapy, biotherapies … there is a wide range of treatments. If none can cure, the number of seizures can be seriously reduced.

Whatever the age, one can suffer from psoriasis. The immune system is racing and the cells of the skin hyperproliferate. It does not matter, but it lasts. Red patches are formed with, in the center, characteristic whitish scales, small dead skin that peel off and fall.

*** No Definitive Cure

If it is known to effectively treat psoriasis outbreaks, the definitive cure is still not possible: the plaques hatch, disappear and often re-offend. Because hereditary, environmental, psychological (trauma or stress) or infectious factors can trigger a crisis. And some drugs (beta-blockers or antimalarials) can make it worse, as can excess alcohol.

The treatments, which have made spectacular progress, help control the outbreaks of the disease. Two parameters guide the choice of treatment: the extent of the lesions and the discomfort felt by the patient.

*** Treat Localized Psoriasis

The dermatologist prescribes a combination of topical corticosteroids and vitamin D derivatives. In the form of cream or foam, it is applied once or twice a day to the plates for more than six weeks. It is effective in the appearance of the skin and on the itching.

*** Treat Diffuse Psoriasis

The sun’s rays improve psoriasis, hence the idea of offering treatments that reproduce solar radiation. Under the control of a dermatologist, phototherapy, which uses UVB, usually makes psoriasis disappear in about thirty sessions (three times a week).

*** Treat More Generalized Psoriasis

The French Society of Dermatology published its recommendations in December 2017. Immunomodulatory therapies reduce the frequency of relapses but, because of their side effects, they require monitoring. Some are contraindicated in pregnant women. Methotrexate tablets (taken all at once to prevent side effects) or subcutaneous injections are the first-line drugs. Then come ciclosporin and vitamin A derivatives, reserved for certain forms of psoriasis.

Biotherapies, powerful immunodulators in infusion or subcutaneous injection, only concern the most affected patients (about 5,000 people in France).

Note :

Treatments can be local and general depending on the extent of the attack.

Local and general treatments may be offered by the doctor depending on the severity of the disease and the possible impact on the quality of life.

Psoriasis can have a strong impact on the quality of life.

The goal of treatment is therefore to improve the acceptability of the disease and, as a result, the quality of life and to control the lesions.

There is no cure that can permanently cure the patient.

Let’s learn more about psoriasis treatments: local and general treatments for psoriasis.

1 – Local Treatments for Psoriasis

Local treatments can be used alone or in combination: emollients, keratolytic, topical corticosteroids, vitamin D derivatives, retinoids … These products are available in lotion, gel, cream or shampoo depending on the location of the plates.

Local treatments are those intended to be applied to the plates. They can be used alone or together, depending on the location and extent of the lesions. Different forms of local treatment exist, adapted to the location and appearance of the lesions: for example, lotions for the scalp, ointments for treating very thick plates, or creams for lesions with little scaly or folds.

*** Dermocorticoids for the Treatment of Psoriasis

Topical corticosteroids are local anti-inflammatory preparations containing cortisone derivatives. They constitute the local reference treatment for psoriasis. They are classified according to their activity:

– very strong activity (class I),

– strong activity (class II),

– moderate activity (class III),

– weak activity (class IV).

Topical corticosteroids are contraindicated for infections or ulceration of the skin. Some preparations associate a topical corticosteroid with a keratolytic substance (see below) or with a vitamin D derivative (see below) or with an antiseptic.

The action of topical corticosteroids is very fast in the treatment of psoriasis and they are often prescribed to relieve the patient without waiting for the effects of more specific treatments. When topical corticosteroids whiten the lesions, the treatment is continued for several weeks, or even months, to prevent relapses. The doses applied are reduced very gradually throughout this period.

Topical corticosteroids have adverse effects that vary depending on the activity of the substance used, the amount of product applied daily, the area of skin treated, the mode of application (with or without a protective dressing), the duration of treatment, age of the patient, etc. These adverse effects are thinning of the skin, rosacea, stretch marks, redness (especially when applied to the face) or, more rarely, localized depigmentation of the skin, the appearance of hair or skin lesions. ‘eczema.

In young children, topical corticosteroids should be used with caution as their active substances may enter the bloodstream.

*** Keratolytic Drugs in the Treatment of Psoriasis

Keratolytics have the ability to dissolve keratin from the skin. They facilitate the elimination of crusts present on the plates. They are useful on very thick plates. The available keratolytic drugs contain salicylic acid plus a dermocorticoid. The interest of this association is not demonstrated.

*** Vitamin D Analogues in the Treatment of Psoriasis

Vitamin D analogues are less effective than topical corticosteroids and may be irritating at the beginning of treatment. In the long run, they are well supported and are used as a maintenance treatment. The combination with a topical corticosteroid at the beginning of treatment allows having a faster effect.

*** Retinoids in the Local Treatment of Psoriasis

Retinoids are substances that regulate the renewal of the skin. While most retinoids are taken orally, there is a local treatment for retinoid psoriasis (tazarotene). This gel is recommended for a few plaques and as a maintenance treatment for these lesions. It is often irritating at the beginning of treatment.

*** Other Local Treatments for Psoriasis

Other local treatments may be proposed to fight against dryness of the skin and dander: oil of cade, emollient skin protector.

Hydration of the skin with emollient para pharmaceutical products is often associated with local psoriasis treatments.

2 – General Treatments for Psoriasis

The general treatments are based on a report showing that the impact of psoriasis on the quality of life is important, they are prescribed by a dermatologist.

The treatment of psoriasis sometimes involves drugs that must be taken orally (by mouth) or administered by injection. These treatments are reserved for severe or moderately severe psoriasis but have a strong impact on the quality of life of the patient (for example, very visible psoriasis that harms his social life).

General treatments for psoriasis use either drug that decrease the activity of the immune system (“immunosuppressants” such as methotrexate or ciclosporin) or a retinoid (acitretin, which regulates skin renewal) or medications which block the action of certain immune substances such as, for example, TNF (Tumor necrosis factor).

*** Methotrexate in the Treatment of Psoriasis

Methotrexate is an anti-inflammatory and immunosuppressive agent. It is one of the reference treatments for severe psoriasis. It is taken once a week, orally or by injection, usually subcutaneously. The most common side effects are malaise, digestive disorders, a drop in white blood cells and inflammation of the mouth. Taking folic acid after methotrexate reduces the frequency of some of these side effects. Patients taking methotrexate should be monitored regularly (clinical examination and blood test) for possible, potentially serious adverse effects on the liver, lungs or blood.

Methotrexate is contraindicated in pregnant women and women of childbearing potential without effective contraception.

In addition, when taking methotrexate, it is best not to take nonsteroidal anti-inflammatory drugs.

*** Ciclosporin in the Treatment of Psoriasis

Cyclosporine, an immunosuppressive drug, has an efficacy comparable to methotrexate. This substance has the property of blocking certain cells which intervene in the immune reactions. These main undesirable effects are renal toxicity, high blood pressure, liver disorders, tremor, tingling of hands and feet, excessive growth of hair, digestive disorders, swelling of the gums.

*** Retinoids in the General Treatment of Psoriasis

Acitretin is part of the family of retinoids. Its effect on psoriasis plaques appears after six to eight weeks. It is more effective in children than in adults. Acitretin can be used alone or in combination with phototherapy (to reduce the doses of ultraviolet light administered).

Its main undesirable effect is the dry skin and mucous membranes it causes.

Acitretin can cause malformations in the unborn child when taken during pregnancy, which requires special precautions. In October 2012, prescription and dispensing conditions were reinforced for women of childbearing age, with the introduction of a care and contraception contract. The patient agrees to use effective contraception one month prior to initiation of treatment, throughout the course of treatment and for two months after the end of treatment (or two years thereafter). A pregnancy test must be performed before treatment, then every month for the duration of treatment, then regularly during the months following the cessation of treatment. In February 2014, following the observation of pregnancies that occurred during treatment with acitretin, the French Medicines Agency restricted the prescribing methods: from now on, the initial prescription must be written by a dermatologist. Renewal of prescriptions can be done by any doctor within one year after which a new prescription by a dermatologist is required (see News).

In addition, taking acitretin contraindicated alcohol consumption and blood donation.

*** Biotherapies in the Treatment of Psoriasis

The drugs of the family of biotherapies are recent in the treatment of psoriasis. Products by biotechnology, they target specific stages of inflammation. Because of the risk of adverse effects, especially infectious, their use is reserved for the treatment of psoriasis resistant to other general treatments, such as ciclosporin, methotrexate or phototherapy. Some of these drugs are also used in the treatment of psoriatic arthritis.

These are expensive drugs that require thorough medical check-up before their prescription. They, therefore, have an exceptional drug status and their prescription is reserved for specialists in dermatology, internal medicine, and rheumatology. The initial prescription must be made at the hospital and renewed annually at the hospital.

– Anti-TNF Agents

Biotherapies in the treatment of psoriasis include anti-TNF agents (adalimumab, certolizumab, infliximab, etanercept). These substances act by blocking the action of a molecule produced by the cells of the immunity, the Tumor Necrosis Factor or TNF, involved in the inflammatory processes of the body.

Before starting treatment with an anti-TNF drug, a preliminary assessment is performed to detect neurological abnormalities, heart or possible infection, even benign. A dental check-up is also done to detect an infection of the teeth that could be complicated by infection of the heart valves. If an infection is detected, it is treated with antibiotics before the initiation of anti-TNF treatment, which will be administered by injection, either intravenously at the hospital during the day or subcutaneously (by a nurse or the patient -even). Patients should be monitored regularly to detect possible infections as soon as possible.

When receiving an anti-TNF drug, it is important to remain alert and report to your doctor any signs that may suggest an infection: fever (even low) or weight loss (even moderate). Indeed, a neglected infection can have extremely serious consequences in people who receive anti-TNF.

– Interleukin Inhibitors

Other biotherapy drugs have an indication in the treatment of psoriasis. They are monoclonal antibodies that inhibit human interleukins, substances that are involved in the inflammatory process: ixékinumab (TALTZ), guselkumab (TREMFYA), ustekinumab (STELARA) and secukinumab (COSENTYX). They are in the form of injectable solutions to be administered subcutaneously. The main side effects are joint pain, headache and injection site reactions. Rare cases of skin damage have been reported (redness, desquamation) with ustekinumab and have been reported by the drug agency (see News: STELARA: risk of skin damage and conduct to hold, 11/2014). They probably present an increased risk of infection, like other biotherapies.

*** Aprelimast in the Treatment of Psoriasis

Aprelimast decreases inflammatory processes by inhibiting an enzyme called phosphodiesterase that is involved in the production of cytokines. It is a second-line treatment of psoriasis in adults in the event of failure, or contraindication, or intolerance to other general treatments including ciclosporin, methotrexate or PUVA. Its effectiveness seems modest, but it may be useful to delay treatment with biotherapy.

The most common side effects are digestive disorders, headaches, and respiratory tract infections. The occurrence of suicidal ideation during treatment should be promptly reported to the physician.

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