Psoriasis is a chronic autoimmune condition that causes inflammation in the skin. Psoriasis causes uncomfortable rashes that are not just unpleasant, but can also be embarrassing and painful.
Different types of psoriasis can manifest with different types of rash, although they are all caused by inflammation in the skin from an autoimmune process.
The most common type of psoriasis, plaque psoriasis, results in patches of colored, scaly plaques that often appear on the scalp, elbows, knees, and lower back. While there is no cure, plaque psoriasis typically follows a pattern of flare-ups and remissions.
Together we’ll discuss the pathology and the symptoms of plaque psoriasis, and discuss effective, research-backed strategies to reduce flare-ups and improve the quality of life for patients living with plaque psoriasis.
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What is Plaque Psoriasis?
Plaque psoriasis is a chronic skin condition caused by an inflammatory autoimmune response that speeds up skin cell production. Genetic, environmental, and immune factors lead to raised, scaly silver-gray patches on areas like the scalp, elbows, knees, and lower back.
Triggers such as skin injuries, infections, certain medications, hormonal changes, alcohol, smoking, and stress can activate immune cells, which release inflammatory molecules. This reaction overstimulates skin cells (keratinocytes), causing rapid turnover and the characteristic scaly patches of psoriasis.
In 2021 it was estimated that over 7.5 million US adults have psoriasis; plaque psoriasis makes up at least 80% of all psoriasis cases.
Symptoms of Plaque Psoriasis
The symptoms of plaque psoriasis can be painful and distressing, seriously reducing a person’s quality of life. Psoriasis symptoms can come and go with flare-ups and remissions, and are characterized as mild, moderate or severe.
Physical Symptoms
Thick Patches of Skin
Plaque psoriasis presents as raised, well-defined symmetrical patches that are red or darkened with silvery-white or gray scales, commonly found on elbows, knees, scalp, and lower back. The patches vary in size and color depending on skin tone and are often symmetrical. Patches are dry, itchy, or sore, and will sometimes crack and bleed, causing an increased risk of secondary infection.
Dry, Cracked Skin that May Bleed
Accelerated skin cell turnover in psoriasis causes dry, cracked skin that can bleed. This rapid turnover increases discomfort and infection risk, often showing the Auspitz sign (pinpoint bleeding when scales are removed).
Itching, Burning, or Soreness
Psoriasis often leads to intense itching, burning, and soreness due to inflammation and the thickening of scaly patches.
Thickened, Pitted, or Ridged Nails
Nail psoriasis results in discoloration, pitting, thickening, and nail separation from the nail bed, affecting both fingernails and toenails, causing discomfort and psychological distress.
Stiff and Swollen Joints
Psoriatic arthritis, associated with psoriasis, leads to joint pain, stiffness, and swelling, especially in fingers and toes, often causing "sausage-like" dactylitis. Psoriatic arthritis can also affect the spine, resulting in back pain and stiffness.
Symptom Severity
The severity of plaque psoriasis is determined by body surface area (BSA) affected and impact on quality of life:
- Mild Psoriasis affects less than 3% of BSA, with minimal impact, managed with routine skincare and topical treatments.
- Moderate Psoriasis affects 3% to 10% of BSA, with significant impact, often requiring more aggressive topical treatments or phototherapy.
- Severe Psoriasis affects more than 10% of BSA, significantly impacts quality of life, and requires systemic treatments like biologics. This is managed by a specialist.
Triggers and Flare-Ups
Common triggers for plaque psoriasis include:
- Mechanical Stress: physical trauma or injury to non-psoriatic skin areas can lead to new psoriasis lesions, a phenomenon known as Koebner’s phenomenon.
- Infections and Skin Dysbiosis: bacterial infections (e.g., Streptococcus, Staphylococcus), viruses (e.g., HIV, HPV, COVID-19), H. pylori and fungal overgrowth like Candida can hyperactivate the immune system, triggering psoriasis flare-ups.
- Common Medications: drugs like lithium, beta-blockers, synthetic antimalarials, and ACE inhibitors can induce or worsen psoriasis by affecting immune and skin cell regulation.
- Environmental Pollution: exposure to pollutants (e.g., carbon monoxide, fine particulate matter) causes oxidative stress and over-stimulates the immune system, damaging skin cells and promoting inflammation.
- Lifestyle Factors: smoking, alcohol consumption, and obesity increase inflammatory cytokines, which can worsen psoriasis symptoms.
- Psychological Stress and Sleep Disturbances: stress and poor sleep affect hormonal balance and immune response, leading to increased production of pro-inflammatory cytokines, exacerbating psoriasis.
- Hormonal and Metabolic Changes: fluctuations in hormones and high levels of free fatty acids can increase inflammation, leading to psoriasis flares.
- Weather and Climate: psoriasis flare-ups are more common during cold and dry weather, especially in autumn and winter, due to reduced exposure to sunlight and lower humidity. Sunlight exposure helps improve psoriasis by increasing vitamin D production and suppressing the immune response, while cold weather limits UV exposure and decreases skin hydration, worsening symptoms.
- Dysbiosis: emerging evidence suggests that the gut and skin microbiome may influence psoriasis.
- Gut Microbiome: alterations in the gut microbiome can impact immune system regulation, potentially contributing to psoriasis pathogenesis. Research has found that psoriasis patients often exhibit reduced gut microbiota diversity and bacterial overgrowth, which are associated with systemic inflammation, mirroring patterns seen in excessive alcohol consumption.
- Skin Microbiome: skin dysbiosis (an imbalance or alteration in the skin microbiome) has also been associated with psoriasis flare-ups.
Causes and Risk Factors
Some people may be more likely to develop psoriasis because of certain underlying causes.
Genetic Predisposition
Psoriasis has a strong genetic component, with a higher risk for those with a family history.
Specific genes, like HLA-Cw6, are linked to early onset and severe cases, which are often triggered by stress, obesity, or infections. HLA-Cw6 influences immune responses, causing increased inflammation and rapid skin cell production.
Other genes related to immune function and skin cell growth also contribute to psoriasis risk.
Immune System Dysfunction
Psoriasis is marked by dysregulation of innate and adaptive immune responses, causing the immune system to mistakenly attack healthy skin cells. This accelerates skin cell growth, forming thick, scaly plaques.
Dendritic cells (a type of immune cell) activate Th17 cells (a white blood cell, another immune cell) which release inflammatory cytokines, leading to inflammation and excessive keratinocyte (skin cell) production, creating a cycle of rapid skin cell turnover typical of psoriasis.
Environmental Triggers
Various environmental factors can trigger or worsen psoriasis symptoms, as discussed above. Patients struggling with psoriasis symptoms should be assessed for exposure to modifiable environmental triggers such as smoking, alcohol consumption, high stress, an inflammatory diet, toxin exposure and others, and as many triggers as possible should be removed.
Diagnosing Plaque Psoriasis
People struggling with symptoms of plaque psoriasis should consult their doctor for a thorough medical assessment. Prior to the visit, it is helpful to gather a personal and family medical history, and to record skin symptoms including what makes them better or worse.
Psoriasis diagnosis is primarily clinical. A primary care provider can diagnose and manage mild to moderate plaque psoriasis, although a dermatologist is an expert at diagnosing and treating psoriasis.
What to Expect During the Consultation
Your healthcare provider will take a detailed medical history including asking about your symptoms, family history, and potential triggers such as stress, injuries, or medications.
They may also inquire about mood changes, symptoms of metabolic syndrome (like weight gain and high blood pressure), cardiovascular issues, digestive symptoms, eye symptoms, and joint pain. Lifestyle factors like diet, exercise, alcohol use, and smoking will also be discussed.
Physical Examination
The doctor will check your vital signs and conduct a thorough exam of your skin, scalp, nails, joints, and eyes. They might also evaluate for cardiovascular and abdominal signs linked to conditions associated with psoriasis, such as cardiovascular disease or inflammatory bowel disease.
Differential Diagnosis
Plaque psoriasis can resemble several other skin conditions including:
Tinea Corporis (Ringworm): a fungal infection presenting with red, scaly, ring-shaped patches. A KOH test can confirm fungal elements.
Eczema (Atopic Dermatitis): causes itchy, red, inflamed patches without the thick, silvery scales of psoriasis; typically appears in skin folds.
Lichen Planus: features flat-topped, purplish lesions, often on wrists and ankles, with white lacy lines (Wickham striae) and mucous membrane involvement.
Seborrheic Dermatitis: similar to scalp psoriasis but with greasy yellow scales and less defined borders; it can coexist with psoriasis (sebopsoriasis).
Contact Dermatitis: dermatitis or skin inflammation that usually appears as red, irritated skin from contact with allergens or irritants.
Patients should be referred to a dermatologist if there is any question of the appropriate diagnosis.
How Psoriasis is Differentiated
Plaque psoriasis can be distinguished by its hallmark features: well-defined, thick, red or darkened patches covered with silvery-white or gray scales.
Unlike other conditions, psoriasis often appears symmetrically on both sides of the body and may be accompanied by nail changes, such as pitting or discoloration.
A history of chronic, recurring episodes, as well as the presence of joint pain or family history of psoriasis, can also aid in differentiating psoriasis from similar-looking skin disorders.
Biopsy and Tests
Psoriasis is clinically diagnosed, so additional testing is rarely required. Clinicians unsure of the diagnosis should refer the patient to a dermatologist, who can order necessary testing.
Occasionally the following assessments may be ordered:
- Skin Biopsy: generally not needed for typical psoriasis cases, but this may be performed for atypical presentations or diagnostic uncertainty to distinguish psoriasis from other skin conditions.
- Blood Tests: not required for diagnosing psoriasis. In severe cases, elevated uric acid and decreased folate levels may be noted. Providers often check for comorbidities by assessing cholesterol, blood sugar, and inflammatory markers like hsCRP, and use autoimmune panels to rule out other conditions, such as rheumatoid arthritis.
- Imaging Tests: X-rays or MRI may be used if psoriatic arthritis is suspected to evaluate joint involvement and detect erosive damage, guided by the Classification Criteria for Psoriatic Arthritis (CASPAR).
Treatment Options for Plaque Psoriasis
Treatment options vary widely depending on the severity of psoriasis.
Topical Treatments
For mild to moderate psoriasis, creams and shampoos with corticosteroids, vitamin D analogs, or coal tar are commonly used to reduce inflammation, itching, and rapid skin cell turnover by applying them directly to affected areas.
Phototherapy
UV light therapy, particularly narrowband UVB (NB-UVB), helps slow skin cell growth and is effective for more widespread psoriasis when topical treatments fail. It can be combined with other therapies and has fewer systemic side effects.
Systemic Treatments
Traditional medications like methotrexate, cyclosporine, and acitretin are used for severe cases, while biologics target specific immune responses for significant symptom relief and management of comorbid conditions.
Biologics (newer, stronger medications) include TNF-α inhibitors, IL-23 inhibitors, and IL-17 inhibitors, and are typically administered via injection or infusion.
Lifestyle Modifications
Stress reduction, exercise, and a healthy diet can help manage symptoms. Specifically, a low calorie diet if weight loss is recommended, as well as the Mediterranean diet, may benefit people living with psoriasis.
Avoiding triggers like smoking and excessive alcohol can also minimize flare-ups.
Home Remedies
Regular moisturizing and sun exposure can reduce the incidence and severity of flare-ups. The National Psoriasis Foundation recommends therapies like topical aloe vera and apple cider vinegar (applied directly or diluted in a bath). They also suggest acupuncture.
Turmeric is an herbal supplement with evidence to support its benefit for psoriasis management.
Managing Flare-Ups and Long-Term Care
Psoriasis is a chronic condition; effective management means regular medical visits and adhering to treatment plans, as well as appropriate diet and lifestyle measures to reduce inflammation and minimize flare-ups.
Identifying and Avoiding Triggers
Understanding personal triggers such as stress, certain foods, or environmental factors is essential for managing psoriasis. Recognizing these triggers and making lifestyle adjustments can help prevent flare-ups and keep symptoms under control.
Consistency in Treatment
Sticking to prescribed treatments, whether topical medications, phototherapy, or systemic drugs, is necessary to manage psoriasis effectively. Regular use of treatments and attending follow-up appointments with a healthcare provider ensures appropriate care and helps to prevent flare-ups.
Monitoring and Adjusting Treatment Plans
Psoriasis can change over time, so it's important to work closely with a healthcare provider to monitor symptoms and adjust treatments as needed. This proactive approach helps maintain symptom control and addresses any side effects or new symptoms promptly.
Support and Mental Health
Psoriasis can affect emotional well-being, leading to feelings of isolation or depression.
Finding support and seeking counseling or other mental health resources can be invaluable in helping people cope with the psychological impact of living with a chronic skin condition.
Living with Plaque Psoriasis
Daily lifestyle choices alongside the right resources and support can go a long way in managing psoriasis symptoms.
Daily Management Tips
- Follow a healthy diet, exercise regularly, and find ways to manage stress to reduce psoriasis flare-ups.
- Enjoy probiotic foods to support a healthy gut microbiome.
- Incorporate gentle skin care routines such as using moisturizers and fragrance-free products, and choose soft, breathable clothing to reduce irritation.
- Get outside when the sun is shining.
Dealing with Stigma
Learn effective ways to address questions or comments about your skin, educate others about psoriasis, and build confidence in social situations to cope with the stigma associated with visible skin conditions.
Building a Support Network
Connect with others who understand your experience by joining support groups or online communities. These communities are also great resources for developing the skills needed to gain confidence and educate others about psoriasis.
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Key Takeaways
- Psoriasis is a chronic inflammatory autoimmune condition that causes uncomfortable, scaly, and painful rashes. The most common form, plaque psoriasis, affects areas like the scalp, elbows, knees, and lower back. It follows a pattern of flare-ups and remissions, influenced by triggers like stress, infections, and environmental factors.
- If you experience symptoms of plaque psoriasis, consult a healthcare provider for proper diagnosis and treatment. Early intervention and working with a specialist like a dermatologist can help manage symptoms and improve quality of life.
- Effective management of plaque psoriasis involves regular use of prescribed treatments, lifestyle changes to avoid triggers, and consistent follow-up with your medical team. Addressing both physical and emotional aspects of the condition can lead to better outcomes and enhanced well-being.
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