Psoriasis is a disease characterized by red scaly plaques that result from over-proliferation and inflammation of the skin due to an intense immunological dysfunction in the skin. Not only does the skin appear abnormal, but often there are symptoms of itch, burning, and discomfort. Psoriasis is associated with arthritis in a significant number of patients. If untreated this can be deforming and disabling. Recent data suggest that cardiac disease can be a side effect of this generalized inflammatory process and often occurs as part of a systemic metabolic syndrome.
Causes of Psoriasis
There is a genetic link that occurs in psoriasis. The precise mode of transmission has not been well clarified. It is not uncommon to see psoriasis in several family members and this disease commonly skips generations. Genetic studies have demonstrated abnormalities even when the skin appears normal. Future research will help us better understand the connection between genes and psoriasis.
Clearly, there are seasonal differences with this condition. It is typically better in the summer with more ultra-violet light exposure and warmer weather. Conversely, it is often worse in the winter due to lack of sunshine and the effect of cold weather on skin barrier function. There are a few patients who are made worse by sun exposure or ultraviolet light treatments. Another skin condition referred to as pityriasis rubra pilaris often can be confused with psoriasis and typically is made worse by ultra-violet light.
Therapeutic treatments for Psoriasis
Topical steroids are the most used product for this condition and may provide rapid improvement.* In the United States, the super-potent steroids are used commonly in adults due to the especially quick response seen with these agents. These agents suppress abnormal skin growth and inflammation.* Unfortunately, they also robustly suppress normal growth and repair which can lead to skin barrier dysfunction and later to atrophy which can be manifested as thin easily bruised skin. Due to these side effects, it is recommended that these stronger super-potent steroids be used for 2-4 weeks and then only intermittently after that.* Unfortunately, patients and physicians often neglect this recommendation.
Vitamin D derivatives are important partners in the treatment of psoriasis.* By themselves, they provide fair improvement over 2-3 months.* However, in combination with topical steroids and Vitamin A derivatives, they can work very well.* These agents regulate immune function, repair barrier function and, most importantly, direct differentiation.* This latter process is important in directing the regular orderly growth of the skin.
Finally, topical Vitamin A has a role in psoriasis treatment. Tazarotene (Tazorac), like Vitamin D, is a useful partner in the treatment of psoriasis.* This drug promotes orderly growth and differentiation of the skin.* It also has anti-inflammatory properties with its effect on toll-like receptors.* Also, this class of Vitamin A derivatives acts as a co-factor with vitamin D and other hormonal agents to orchestrate the metabolic functions of many cells.*
Tars have traditionally been used in psoriasis. 5% crude coal tar and other tar derivatives are effective but are difficult to use in a home situation where tar easily stains clothing and other objects that it comes into contact with.* Anthralin, a tar derivative, can be used successfully by leaving it for 20-30 minutes and then washing it off.* This is referred to as “minutes” therapy and can be effective.* Unfortunately, Anthralin stain objects much like the other tar derivatives. For this reason, these products have limited use.
Phototherapy has been a useful treatment for psoriasis for 100 years.* Narrow band UVB and the Excimer laser are the most modern tools available to treat this problem.* We were the first to introduce phototherapy to Sacramento and maintain a full line of devices that can be tailored to an individual’s current needs. Dr. Tanghetti trained at the Wellman lab of Harvard University in all aspects of phototherapy and laser surgery. We also use PUVA therapy, a form of oxsoralen and UVA light, to treat more resistant forms of psoriasis and eczema, especially on the palms and soles of the feet. We also use it to treat T-cell lymphoma of the skin and Mycosis Fungoides.
Dr. Tanghetti has 30 years of experience using systemic treatments for psoriasis. We regularly utilize Soriatane, a systemic retinoid, and a number of biologic therapies for severe psoriasis.* Our experience with biologic agents is broad and includes clinical as well as experimental work with most of these agents. Most often they are used in combination with other topical treatments and phototherapy.*
Most patients are treated with a combination of agents, which permits better efficacy and less toxicity. We have a great deal of experience in picking the proper agents that will best fit an individual’s needs and situation. We would be happy to schedule a consultation to discuss these further – to do so, please call us at 916.454.5922 or fill out a contact form.