Psoriasis Information

Psoriasis

Everything we know about psoriasis.

What is Psoriasis?

Psoriasis is a reaction of the immune system that accelerates the skin cell cycle. It causes skin cells to reproduce rapidly in the upper layer of the dermis. The excess skin cells create itchy, reddish scales and patches and some produce pustules that are very painful when they dry out. Psoriasis is a chronic disease that sometimes goes away and comes back.

To date, no cure has been found for psoriasis, but its symptoms can be controlled.

And in Nopsor we found the formula that helps to control it.

Depending on the study, the percentage of people affected by psoriasis is presumed to be between 2% and 3% worldwide. (IFDA) (AAD)

The life expectancy of people with Psoriasis and people without Psoriasis is similar. The prevalence of psoriasis increases with age. (Bonifai et al. 1998)

When was Psoriasis discovered?

From ancient times, Hippocrates (460-377 BC) described various skin symptoms such as dryness and scaling under the term "lopoi" = epidermis.

Psoriasis was even confused with leprosy for many centuries. (Wahba et al. 1980)

In 1809, Robert Willan was the first to give an accurate description of Psoriasis. However, it took many more years for Psoriasis to be separated from Leprosy.

How do psoriasis lesions manifest themselves?

Psoriasis lesions manifest themselves in a variety of ways, from small dots to large plaques, or even erythroderma which is a medical term to describe an intense and widespread reddening of the skin as a result of inflamed skin.

Psoriasis type Erythroderma
If the clinical picture is dominated by small lesions, it is described as Psoriasis Guttate.
If the lesions are the size of a coin or even the size of the palm of the hand, it is described as chronic plaque psoriasis.

There is also a subclassification of plaque psoriasis known as Psoriasis Vulgaris which is estimated to affect 90% of psoriasis patients. The term vulgaris comes from the Latin word meaning common. In other words, common psoriasis.

Psoriasis vulgaris or commonpsoriasis
If skin inflammation is predominant, pustules are the most important sign and are described as Pustular Psoriasis.
Definition of pustule: a small, circumscribed elevation of the skin containing fluid, usually purulent.
Palmoplantar psoriasis (feet and hands) may occur with or without the presence of lesions on other parts of the body. The scales are often deep-seated and often break.

The sacral region is the favourite part of Psoriasis. And if you are wondering what the sacral region is, we remind you that it is defined as the lower part of the spine and is located between the fifth segment of the lumbar spine (L5) and the coccyx. The sacrum is a triangular shaped bone with five segments (S1 - S5) fused together. In other words, at the division of the buttocks.

Flexible regions such as armpits, knees, elbows, breasts, groin, etc.

Mucous membranes as reproductive organs

Psoriasis on the nails

Psoriasis on the fingernails is more common than on the toenails. Nail changes are more common in patients with whole body psoriasis. (Calvert et al, 1963)

Psoriasis lesions

Psoriasis lesions are mostly of the polycyclic type, indicating that the lesion is made up of several smaller lesions and sometimes the lesion is demarcated by a whitish ring. (Woronoff 1926)

The main characteristics of a Psoriasis lesion are scaling, hardening and inflammatory redness.

The sensation of a Psoriasis lesion can be painful when the lesion is dry and cracked.

Although itching manifests itself during the gestation of the lesion, it is not considered a characteristic symptom of Psoriasis.

Psoriasis is not expressed in a static but in a dynamic way, i.e. lesions can grow and then regress. The period is dynamic and can be considered short (weeks to months) or long (months to years). Genetic elements and the triggers of psoriasis in each person play a role in this dynamic.

Latent psoriasis

Since psoriasis is partly genetically determined, this implies that there are many people with latent psoriasis which means that they already have psoriasis, but have not developed any symptoms.
Some triggers of latent psoriasis have been identified and are listed in the following table:

Infection	Demonstration
Fever	Psoriasis Vulgaris
Viral Infection	Psoriasis Guttate
Tonsillitis	Pustular Psoriasis
Bronchitis	Psoriasis Guttate
Pharyngitis	Psoriasis Guttate

Infections and psoriasis (Holzman et al, 1974) - These are just a few for reference.

There are also endocrine factors that activate latent psoriasis, such as hormones that play an important role in the pathology of psoriasis. That is why many cases of psoriasis start at puberty and many at menopause.

Psychogenic factors such as stress are well correlated with psoriasis activity.

On the other hand, drugs have also been identified that activate latent Psoriasis such as:

Anti-malaria
Lithium
Practolol
Corticosteroids
Indomethacin

Dermatitis associated with Psoriasis

Skin cancer

Kocsard (1976) reported that psoriasis is virtually absent in patients with sun-related skin cancer or solar keratosis. The prevalence of the combination of psoriasis and melanoma seems to be very low or lower than the expected number of cases (Proctor et al, 1981).
However, Halprin et al (1982) reported a high frequency of skin cancer with psoriasis in those who had undergone treatments such as: Ultraviolet rays, Metrotexate, X-rays or Corticosteroids among others.

Various types of Eczema

Seborrhoeic Dermatitis

Diagnosing psoriasis or seborrhoeic dermatitis on the scalp or joints is very difficult. Seborrhoeic dermatitis is typically distinguished by a more yellowish and greasy appearance, sometimes accompanied by hair loss and the lesions are not as easily palpable as in psoriasis.
Atopic Dermatitis

According to Puerschel (1973) coexistence between psoriasis lesions and atopic dermatitis is rare. He found only 3 cases of psoriasis in a group of 1,170 patients with atopic dermatitis. It is recommended to see a dermatologist for histology to determine whether it is psoriasis or atopic dermatitis.

Contact eczema

When the skin comes into contact with a substance to which one is allergic, it causes redness and itching of the skin. In 1967 Steigleder & Orfanos reported that in most of their patients studied it was likely that the psoriasis lesion was caused by contact eczema.

Plaque Psoriasis

Plaque psoriasis marks are lesions with red, raised scales. These raised areas are known in dermatology as plaques. In contrast to other inflammatory skin lesions, plaque psoriasis has well-defined borders.

A typical plaque rises 2-3 millimetres above the skin surface (epidermis), is scaly and shows a reddish appearance with well demarcated borders. The colour may vary depending on the skin type and the location of the lesion on the body.

The scales can be separated from the skin either with a sharp object or typically with the fingernails. When the lesion is scratched continuously the reddish colour of the scale changes and the surface becomes opaque. If the scales are detached from the plaque a thin membrane becomes visible, which represents the last keratinocyte layers of the lower epidermis (Stratus Spinosum).

Patients with plaque psoriasis suffer from psychological symptoms because scaling is frequent and is evident wherever they walk or on their clothes.

Specific locations of Plaque Psoriasis

Psoriasis on the scalp (Scalp Postriasis)

The most common area affected is the scalp. Generally speaking, the lesions are similar to those occurring on the rest of the body, but are more difficult to observe and examine as they are covered with hair. These lesions typically only sprout on the scalp where hair is growing and areas of the scalp with signs of baldness typically do not. The lesions may protrude up to 1 centimetre from the edge of the hair area and are the same as plaques on other parts of the body, although sometimes their reddish appearance takes on a yellowish cast.

Psoriasis intetriginosa

Intertriginous is a medical term used to define an area in two areas of the skin that may touch or rub together. Examples of intertriginous areas are the armpit of the arm, the anogenital region, nostrils, skin folds of the breasts and between the fingers.

Unlike other plaque psoriasis lesions, these lesions change their morphology where the scales instead of being silvery and dry look reddish and shiny as if they had wax on them.

Inverse Psoriasis

Describes lesions that are located on the inner side of the joints and is separated from other lesions because it can be confused with Atopic Dermatitis. The lesions typically produce small to medium-sized scales.

Palmoplantar Psoriasis

This is one of the most difficult because of its psychological effects on the patient, as the hands in particular are not covered by clothing and most activities require the use of them, making it impossible to do many jobs due to people's rejection. The lesions are similar to those in other areas of the skin, but more difficult to treat due to the thickness of the epidermis.

Kobner effect

This term is used when psoriasis lesions sprout on areas of skin that have previously suffered physical trauma. A week or two after the trauma, skin that was not necessarily involved in the trauma will sprout psoriasis and the shape of the psoriasis lesion will be similar to that of the trauma. In fact, Henrich Kobner of Berlin, Germany, described a horse-driving patient who was bitten by a horse on his upper arm and two weeks later developed psoriasis lesions in the shape of the bite.

Psoriasis Guttate

Psoriasis guttate is discussed as a specific manifestation of psoriasis and not as a variant of plaque psoriasis. It typically occurs in children, young adults and often as the first manifestation of psoriasis.

It manifests itself suddenly as small pimples and plaques measuring from a few millimetres to 1 to 2 cm in diameter. It can occur all over the body and does not cause as much scaling as plaque psoriasis.

In addition to the skin symptoms described above, some patients have symptoms of fever and fatigue.

There are some skin diseases that are confused with Psoriasis Guttate such as Psoriasis Rosea which occurs at the same age as Psoriasis Guttate. Patients also develop reddish, scaly lesions several centimetres in diameter known as the primary medallion. This does not exist in Psoriasis Guttate. The lesions of Psoriasis Rosea are larger than those of Psoriasis Guttate. It is also rare for Psoriasis Rosea to occur on the face.

Pustular Psoriasis

These types of pustular lesions are less common than erythroderma-type lesions (reddening of the skin). Guttate or plaque psoriasis lesions typically anticipate the appearance of pustular lesions.

Factors that trigger Pustular Psoriasis

Progesterone (Pregnancy)

At the end of the second part of pregnancy this hormone increases and it has been described in studies such as that of (Murfy & Stoleman, 1974) that after administering this hormone pustular psoriasis is triggered.

Corticosteroid therapy

In a study by (Brian & Baker, 1968) 37 out of 104 patients studied with pustular psoriasis had received corticosteroid treatment.

Irritants such as pyrogallol or dithranol or an overdose of ultraviolet rays also trigger Pustular Psoriasis.

Infections - especially of the respiratory tract

Eruption patterns of pustular psoriasis

Pattern - is defined as a repetition or recurrence of certain characteristics.

Zumbush pattern - Characterised by the abrupt eruption of erythema and pustules. During this phase the skin is very painful, the patient feels ill and sometimes feverish. After several days or weeks, the pustules disappear and a desquamation proceeds. The skin typically clears and the desquamation ceases.

Annular (Circle or round)pattern - the rash is characterised by round lesions that are more or less spread out. The lesions consist of erythema (redness) and scaling with pustules at the periphery. The lesions gradually grow and may last for weeks, months or even years. Sometimes they can grow within hours and last for weeks (Lapiere, 1959).

Exanthematous type pattern (Exanthema = skin rash) - An acute rash of pustules and erythema. The rash sometimes starts on the palms of the hands and soles of the feet, and then spreads abruptly over the rest of the body.

The term pustular psoriasis encompasses several subtypes of pustular psoriasis:

Generalised Pustular Psoriasis (GPP)

Pustular Psoriasis during Pregnancy (PPPP)
Annular (circle or round) psoriasis (EACP)
Psoriasis vulgaris pustulosa
Pustular Palmoplantar Psoriasis (PPP)
Psoriasis Hallopeau

GPP - Generalised Pustular Pustular Psoriasis

It is also known as the Zumbusch pattern as Leo Ritter von Zumbusch was the first to describe this type of lesion in 1910. This type of lesion is known to be the most severe of all types of psoriasis including possible life-threatening effects.

Inflammation is more pronounced than plaque psoriasis and the following triggers of plaque psoriasis have been reported:

Respiratory tract infections, especially streptococcal and vaccine-associated infections
Chemical, physical and mechanical factors, e.g. solar irradiation or irritating topical substances.
Hypocalcaemia
Hormonal changes, pregnancy, oral contraceptives, stopping corticosteroid use
Stress due to strong emotions or complicated situations such as divorce, accidents, loss of loved ones, financial situations, etc.
Medications such as lithium, beta-blockers, anti-malarials, ACE inhibitors such as ramipril or topical indomethacin.

Clinical picture

Pustular psoriasis is characterised by a sudden outbreak of erythema with a rapid spread of small pustules. These pustules may appear within a few hours, but may last for several weeks. Often these pustules coalesce and form pus lesions.

When the pustules rupture and dry, the skin sloughs off, resulting in skin erosions that can become infected. This disease sometimes includes several cycles of eruption, pus, rupture, drying and sloughing of the skin. While the lesions show desquamation, new lesions with pustules may erupt and an expansion of these lesions may eventually create erythema (redness of the skin). The face is not normally affected by pustular psoriasis but nails, palms of the hands and soles of the feet may be affected.

GPPP - Generalised Pustular Psoriasis during Pregnancy

GPPP has been accepted as a variant of annular pustular psoriasis described below and occurs during pregnancy due to hormonal disruption.

Psoriasis Annulare or EACP - Erythema Annulare of the Centrifugal Pustular type)

This type of psoriasis was reported by Lapiere in 1959, and later Huriez and Degos introduced the term (EACP). This is a rare variant of psoriasis that suddenly flares up in patients with no history of psoriasis such as patients with plaque psoriasis or pustular psoriasis.

Clinical picture

Annular (circle or round) psoriasis is characterised by erythema (redness) or discrete ring or snake-shaped plaques (curved lines). The lesions are covered with pustules and the course of these lesions causes it to arise suddenly and recede in the same way. This can happen over weeks or several months.

Psoriasis Vulgaris with postulation

This term is used when pre-existing psoriasis vulgaris develops pustules on the psoriasis plaques.

Palmoplantar psoriasis pustolosa

This psoriasis, known as PPP, was first described in 1888 by Crocker as Dermatitis repens and was associated with psoriasis until 1930.

Clinical picture

PPP manifests in patients with no history of psoriasis. Women are more affected than men by a ratio of 9 to 1, showing first symptoms in the 3rd and 4th decade. Interestingly, up to 95% of patients are former or current smokers.

Initially, small yellow pustules sprout from side to side of old, dry pustules. Some patients have the lesions on only one area of the palms or soles of the feet.

Psoriasis Hallopeau

The name comes from the French dermatologist François Henri Hellopeau (1842-1919). It has been classified as a subtype of plaque psoriasis, although it remains controversial.

Clinical picture

Lesions typically start from an area of trauma or infection, often involving one or two fingers or toes. Pustules (reddish) are generated in the erythema; when the pustule matures, pus is generated.

This section will cover the most common treatments and the Nopsor treatment falls into the topical category and uses some of the elements described here plus a proprietary herbal blend that has made Nopsor work for most people without rebound.

Topical Treatments for Psoriasis

Topical treatments can be used for any type of psoriasis, either as a monotherapy or in combination with other treatments.

There are several criteria for assessing which treatment to apply:

Location of Psoriasis
Severity of injuries
Reaction to previous treatments
Understanding the risk vs. benefit of treatment
Cost of treatment

In order to select a topical agent for the treatment of psoriasis, it is important to understand and know what factors determine the risk and effectiveness of the agent: how the agent is metabolised in the skin, the vehicle of application, the concentration of the drug and the frequency of application.

There are various application vehicles such as creams, ointments, lotions, gels, shampoos and medicines.

For the topical treatment of psoriasis there are several medications or drugs available:

Corticosteroids
Vitamin D analogues
Retinoid
Tar
Ditranol
Calcineurin

Corticosteroids

Steroids are man-made medicines that resemble cortisol, a naturally occurring hormone from the adrenal gland. These man-made corticosteroids are also sometimes called steroids, confusing the artificial with the natural.

Corticosteroids are thought to act by binding cortisol (adrenal gland hormone) to the glucocorticoid receptor (protein) that is involved in development, metabolism and the immune system. This elicits a variety of biological responses to corticosteroids that can be favourable or unfavourable. These actions can result in anti-inflammatory, anti-proliferative and immune-repressive effects. One way to simplify the above is that they suppress the immune system. Corticosteroids are available in various dosages which gives versatility of application.

Risks of corticosteroids

Corticosteroids are associated with side effects including skin atrophy, stretch marks, cataracts, glaucoma, vulnerability to infection, diabetes, hypertension, osteoporosis, and more.

Most side effects are associated with prolonged use of corticosteroids.

Vitamin D analogues

Vitamin D is generated in the skin and can be taken as a supplement or found in food. From there it travels to the liver to make vitamin D in the blood called calcidiol. From there it goes in two directions to perform two functions. The first function is endocrine and is to maintain calcium in the body. The second function takes vitamin D from the blood and sends it to the cells of the body. And this is where it is believed that vitamin D when it binds to the receptor, it activates and modulates genes that work with epidermal proliferation, inflammation and keratinocytes.

A vitamin D analogue is a chemical compound that has the same structure as vitamin D.

Today there are 3 vitamin D analogues available for the treatment of psoriasis: Calcitriol, Tacalcitol and Calcipotriol.

Calcitriol is an active hormonal analogue of vitamin D, Tacalcitrol and Calcipotriol are synthetic vitamin D analogues.

Retinoid - Tazarotene

Tazarotene is a synthetic retinoid with an affinity for the retinoid receptor. It has been shown to cause anti-proliferation and anti-inflammation. Prolonged use is strongly discouraged as it causes skin irritation, erythema and burning.

Dithranol

Dithranol induces radicals in the skin that result in anti-proliferation and modulation of inflammation in Psoriasis.

Risks: The dithranol molecule is unstable, therefore standardisation of formulations is poor. There is not yet much evidence on the efficacy and risks of this treatment.

Tar

Tar is a distillate product of organic materials such as wood, shale and coal.

Coal tar, which is a type of coal, is used for psoriasis and has been used for over 100 years for this purpose. Coal tar contains hundreds of chemical compounds. Exactly how coal tar works is unknown, but it is known to help with anti-inflammatory and anti-proliferation effects. Although many studies are still lacking to corroborate its efficacy, coal tar is known to have longer-lasting effects than corticosteroids.

Risks: Staining, soiling, odour, irritation, and in some cases allergic skin reactions.

The Nopsor treatment uses coal tar in its formula.

Calcineurin

Calcineurin is an enzyme that catalyses the dephosphorylation reaction of a phosphoprotein (protein). Its effect is to inhibit T-cell activation.

Nopsor Treatment - Describe it

Biological Treatments for Psoriasis

The term biological indicates that they are derived from biological sources such as human or animal cells and are used as therapeutic mechanisms. Most of them are made using biological engineering methods. In short, the genetic information of a protein is transferred into a cell line to induce the production of this protein.

The substances used for the treatment of psoriasis can be divided into 3 types:

TNF alpha
Anti-p40 antibody
Alfacept

Risk of biological medicines: High risk of respiratory tract and skin infections. May also reactivate tuberculosis.

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Psoriasis

Infection

Demonstration

Dermatitis associated with Psoriasis

Topical Treatments for Psoriasis

Biological Treatments for Psoriasis