Psoriasis descriptions, causes, and patterns.
Symptoms of Psoriasis
Psoriasis can occur in several different forms. All types of psoriasis are caused when the infection-fighting white blood cells, called T-cells, malfunction. Under normal circumstances, T-cells fight against foreign invaders. However, in individuals with psoriasis, the T-cells actually attack the skin. The rash of psoriasis results from a combination of damage to the skin by T-cells, inflammation in the skin, and overproduction of new skin cells. To effectively treat your psoriasis, you must first identify the type of psoriasis you have.
Plaque-type psoriasis is the most common form of the disease. It is characterized by inflamed skin lesions topped with silvery white scales. The scales are actually a buildup of dead skin cells. The technical name for plaque psoriasis is psoriasis vulgaris (vulgaris means common). It is most commonly found on the elbows, knees, scalp, sacrum, umbilicus, intergluteal cleft, and genitalia. Sometimes the patches of infected skin are large, extending over much of the body. The patches, known as plaques or lesions, can wax and wane but tend to be chronic. These can be very itchy and if scratched or scraped they may bleed easily.
The actual appearance of the plaques can depend on where they are found on the body. Plaques found on the palms and soles can be scaly, however they may not be very red in color. This is due to the thickness of the skin at these sites. The plaques usually have a well-defined edge and, while they can appear anywhere on the body, the most commonly affected areas are the scalp, knees and elbows. The face is rarely affected. However, if the scalp is involved, you may develop psoriasis on the hairline and forehead. If the plaques are in moist areas, such as in the creases of the armpits or between the buttocks, there is usually little or no scaling. The patches are red and have a well-defined border.
Chronic (or common) plaque psoriasis affects over 90% of sufferers. It appears usually on the scalp, lower back, elbows, arms, legs, knees and shoulders. It is very much an adult condition and is seldom seen in children. Chronic plaque psoriasis is not always itchy, nor is it always an uncomfortable condition, but its appearance, along with the shedding of the skin, can cause many sufferers a great deal of emotional discomfort.
Each psoriatic patch looks like a series of little discs or plaques that have super-imposed themselves on to the body. This plaque-like shape is peculiar to this form of the condition and is what gives it its name. The plaques are often round or oval in shape or they may not have a distinct shape, but they almost always stand out from the surrounding area of the body. The difference between the normal skin and the area affected by psoriasis can be quite marked. Each patch can start as a very small lesion, and then enlarge over a period of days or weeks. Individual psoriatic patches can spread and join with each other to affect a large area of the body. In a typical flare up, the condition can spread quite quickly over a few days or weeks and then stabilize before gradually disappearing. The psoriatic patches become less red and scaly until they reduce in size or disappear completely.
Guttate psoriasis is characterized by small red dot-like lesions. Guttate is derived from the Latin word gutta meaning "drop." It may be described as looking like a drop of psoriasis. It is most common in children and young adults who have a prior history of upper respiratory infection, pharyngitis, or tonsillitis (Camisa 64). The lesions are not as scaly as plaque-type psoriasis and are likely to be found on the trunk and involve the face. The lesions may have some scale. Guttate psoriasis frequently appears suddenly following a streptococcal infection or viral upper respiratory infections. There are also other events that can precipitate an attack of guttate psoriasis: tonsillitis, a cold, chicken pox, immunizations, physical trauma, psychological stress, illness, and the administration of anti-malarial drugs. Guttate psoriasis usually responds to treatment and may gradually go away on its own. Many people who have an episode of guttate psoriasis may not have another one for many years. Guttate Psoriasis is most common in children and young adults who have a prior history of upper respiratory infection, pharyngitis, or tonsillitis. The lesions are not as scaly as plaque-type psoriasis and are likely to be found on the trunk and involve the face. The facial lesions of guttate psoriasis should not be confused with the papules of rosacea. Rosacea is an inflammation of the skin with resulting facial redness and symptoms of vasculation of spidery blood vessels, swelling, and rosacea papules which are red solid elevated inflammatory skin lesions without pus.The guttate form of psoriasis is relatively uncommon. Fewer than 2% of those with psoriasis have the guttate type. Guttate psoriasis is more common in children and adults younger than 30 years. Boys and girls are equally affected. An outbreak of guttate psoriasis may be an immune reaction that is triggered by a previous streptococcal infection or some other type of infection. Guttate psoriasis is also known as Eruptive psoriasis and is considered the least severe form of psoriasis
Pustular psoriasis is characterized by pustules, which are blister-like lesions of non-infectious fluid, and intense scaling. Individuals with pustular psoriasis are often among the most seriously ill and may have to be hospitalized (Camisa 67).This type of psoriasis usually appears as a large red area covered with yellow-green pustules. They tend to be one to two millimeters in diameter and are quite tender. The yellow color is caused by masses of white blood cells (polymorph leucocytes), which flood into any part of the skin that is damaged or infected, in order to fight infection and aid recovery. After seven to 10 days, the pustules become dispersed and a brown scale appears. This scale will start to shed as new pustules develop in other areas, often in a continuous cycle. The most common type of pustular psoriasis affects the palms and soles. It isn't normally itchy however it can be sore or uncomfortable to use either your hands or feet, for example if you are writing or walking. The changes in your skin that you observe prior to, during, and following an episode of pustular psoriasis may be quite similar to or even mistaken for other forms of psoriasis. Psoriasis symptoms include patches of raised skin with areas of scaling.
Pustular psoriasis can be classified depending on the severity of the symptoms:
1) Acute in which the symptoms appear suddenly and are severe in appearance.
2) Chronic, which are, classified as long-term episodes, which re-occur frequently.
3) Sub-acute which a classification in-between sudden and severe episodes and long-term re-occurring episodes.
Pustular psoriasis is further divided in subsets defining specific symptoms and conditions in which it occurs:
Generalized pustular psoriasis is spread over wide areas of the body, is also called von Zumbusch pustular psoriasis, named after the physician who first described it in the early 1900s. Generalized pustular psoriasis is identified with acute symptoms, fever, and toxicity. Called generalized due to the general reddening and inflammation of the skin with sheets of small pustules merging into larger sheets mark generalized pustular psoriasis. The condition begins with the development of reddened, painful and tender skin over much of the body, followed in a matter of hours by pustules. Over the next one to two days, the pustules will dry, peel, and leave the skin with a glazed, smooth appearance. Episodes often occur in waves that last for several days or weeks. Von Zumbusch pustular psoriasis is associated with fever, chills, severe itching, dehydration, rapid pulse rate, exhaustion, anemia, and weight loss and muscle weakness. Treatment for von Zumbusch pustular psoriasis often requires hospitalization for dehydration and initiation of topical and systemic treatments, which typically include antibiotics. Von Zumbusch pustular psoriasis can be triggered by an infection; sudden withdrawal of topical or systemic steroids; pregnancy; and drugs such as lithium, propranolol and other high blood pressure drugs; iodides and indomethacin.
In Palmoplantar pustulosis, the pustules are more localized, occurring primarily on the palms of the hands and soles of the feet. Palmoplantar pustulosis is characterized by multiple pustules the size of pencil erasers in fleshy areas of the hands and feet, such as the base of the thumb and the sides of the heels. The pustules appear in a studded pattern throughout reddened plaques of skin, then turn brown, peel and become crusted. The episodes occur in cycles, with flares of pustules followed by periods of low activity. Research has suggested that an abnormal response to nicotine can trigger flares in individuals with palmoplantar pustulosis.
Acropustulosis also called Acrodermatitis Continua of Hallopeau. This is a less common form of pustular psoriasis is characterized by skin lesions on the ends of the fingers and sometimes the toes. The eruption occasionally starts after an injury to the skin or infection. Often the lesions are painful and disabling, resulting in a deformity of the nails. Bone changes can occur in severe cases.
Annular pustular psoriasis is a ring-shaped form of pustular psoriasis. It is usually sub acute or chronic, and people with this type do not usually have symptoms aside from the skin symptoms. Annular pustular psoriasis tends to have a ring-like appearance where the outer margin is red with lighter or normal looking skin inside the circle. Annular pustular psoriasis is a rare variation of pustular psoriasis which has a tendency to spread and form enlarged rings. It is the most common form of pustular psoriasis in children but can occur in adults also.
Infantile pustular psoriasis is a form of pustular psoriasis that tends to occur during infancy. The skin under and around the pustules is red and has a tendency to occur in repeated waves with frequent spontaneous remissions. The symptoms of Infantile pustular psoriasis include; raised pus-filled skin bumps, skin redness around pustules, stinging, burning sensations, itching and peeling skin.
Erythrodermic psoriasis is the least common form of psoriasis which the rash is spread over large sections of the body and is characterized by intense redness and swelling, exfoliation of dead skin, and pain. It most commonly appears on people who have unstable plaque psoriasis, where lesions are not clearly defined. Erythrodermic psoriasis usually develops during the course of chronic psoriasis, however in some cases it may be the initial type of psoriasis even in children (Camisa 74). Individuals with this type of psoriasis may experience chills, low grade fever, and may be rather uncomfortable. Erythrodermic psoriasis appears on the skin as a widespread reddening and exfoliation of fine scales, often accompanied by severe itching and pain. The skin is very inflamed which affects its ability to function properly. It does not retain fluid as normal, which results in the patient feeling constantly thirsty and being dehydrated. It also impairs the skin's performance in maintaining body temperature control so the sufferer may lose heat more easily and be more susceptible to hypothermia. This is also a more serious form of the condition and one that needs expert medical management.
Inverse or Flexural psoriasis is characterized by smooth inflamed lesions in the body folds -- armpits, under the breast, skin folds of the groin, buttocks, and genitals. Inverse psoriasis is particularly subject to irritation due to rubbing and sweating. Sometimes there is a crease in the center of the patch that may crack open, bleed or become infected. The rubbing together and sweating if the skin folds aggravates irritation of the affected areas. Inverse psoriasis appears in the body folds; the armpits, under the breast, skin folds of the groin, buttocks, and genitals. Inverse psoriasis is also known as flexural because is occurs in the folds of the skin.This type of psoriasis is often white in color, appears softened as if soaked by water, and may resemble a fungal infection. There is very little scaling, although the patches are inflamed and can be very sore. Appearing as it does in the folds of the skin, it is moister than other forms of psoriasis, and can be more uncomfortable physically. Flexural psoriasis rarely occurs by itself. It is more likely to accompany common plaque psoriasis. Psoriasis sufferers in their middle years or old age are more susceptible to this type of psoriasis as are people who are overweight and have more folds of skin.
Koebner's Phenomenon psoriasis are psoriatic lesions which appear at the site of injury, infection or other skin psoriasis, or may be a new lesion in an existing case. The “Koebner phenomenon” was named after Dr. Koebner who in the 19th century observed that a patient developed new psoriasis lesions in areas where his horse bit him. This relationship between skin injury and developing new psoriatic lesions has been observed in many patients. In the Koebner phenomenon, people with psoriasis observe new lesions 10 to 14 days after the skin is cut, scratched, rubbed, or severely sunburned. The degree of psoriasis can also vary from individual to individual. It ranges in severity from mild (affects less than 2% of body) to moderate (affects 2-10% of body) to severe (affects greater than 10% of the body). Skin injury and irritation, sun exposure, diet, stress and anxiety, medications, and infections have been known to make psoriasis worse.
The cause of the Koebner phenomenon is unknown, however, it is more prevalent in patients who develop psoriasis before age 15. Up to 50% of psoriasis patients will experience new lesions forming at the site of healing wounds. Approximately 10% of psoriasis sufferers experience the Koebner Phenomenon with every skin injury or condition, and its chances of occurring increase when the psoriasis is in an active stage.
Skin conditions that have been found to trigger Koebner’s phenomenon include: any type of dermatitis, a Herpes breakout, skin boils, Lichen Planus, and Vitilgo. Koebner’s phenomenon can also result from trauma to the skin from such factors as insect bites; irritation resulting from a chemical reaction on the skin; injuries to the skin such as burns, bruises, cuts or scrapes, sunburn, or skin chafing; skin procedures such as tattoos or acupuncture. In some cases shaving or even the adhesive from a band aid can result in Koebner’s phenomenon. In rare instances, it has been known to occur at the site of an old scar.
Psoriatic arthritis usually occurs in the joints of the fingers and toes. Arthritic disease causes painful inflammation of one or several joints, with the inflammation destroying the cartilage in the joints Arthritis is the term used to identify joint disease from a number of causes. Psoriatic arthritis can be a serious disease, with a large percentage of patients reporting that their symptoms limit their work or home activities. Psoriatic arthritis is usually less painful than rheumatoid arthritis.The symptoms of Psoriatic arthritis include one or more of the following conditions; pain in one or more joints, stiffness in the joints in the morning, movement in the joint is restricted by pain, ocular redness or eye pain. Up to 80% of psoriatic arthritis sufferers report pitting and ridges in finger and toe nails. These characteristic nail changes are rarely observed in psoriasis patients who do not have arthritis. Patients with psoriatic arthritis often report the occurrence of acne as well as changes in their nails. Acne has been noted to occur in the majority of patients with psoriatic arthritis leading one to suspect a pH imbalance. The body is a complex system of action and reaction. Acne and psoriasis partially result from an overly acidic body and skin. The pH or potential of hydrogen ranges from 0 to 14 with 7 being neutral. The causes of acne are the result of will see that acidic reaction caused by the inter action with foods, drinks, stress, or lack of breath due to not enough oxygen - oxygen being an alkaline action and the inability to exhaust enough carbon dioxide - carbon dioxide being an acidic reaction. If you hold your breath for 30 seconds or 60 seconds, you will note that your face turns pink or red in color, this is the result of a build up of carbon dioxide that is an “acidic” gas caused by a shortage of oxygen.
Seborrheic scalp psoriasis usually consists of red, scaly patches that may appear lumpy. The edges of these patches tend to be well defined. Psoriasis on the scalp is common and, in many cases, it is the only area affected. Seborrheic scalp psoriasis can extend beyond the hairline, onto the forehead. Psoriasis of the scalp does not damage the hair follicle and is not associated with hair loss, but if the scale is thick and forms hard lumps, it may lead to temporary hair thinning. The scalp may be the first site on the body to be affected by psoriasis.
Scalp psoriasis can be very mild, with slight, fine scaling. It can also be very severe with thick, crusted plaques covering the entire scalp. Seborrheic scalp psoriasis can be extremely uncomfortable. It is often very itchy, and the psoriatic patches that are inflamed and sore can start to bleed if they are scratched or picked. Seborrheic scalp psoriasis is not caused by poor hygiene or hair care. Itchiness can inflame and irritate the condition.
Seborrheic scalp psoriasis may resemble severe dandruff. Patches of thick, flaky skin may extend to the forehead below the hairline. Scales may build up in the outer ear. The face itself is usually unaffected; this is an important feature in the diagnosis of scalp psoriasis due to the fact that with rosacea you can have episodes of seborrheic dermatitis. Seborrheic dermatitis involves overactive sebaceous glands, which cause inflammation, flaking and a red rash in the central portion of the face. If one looks closely, the flakes usually have a greasy look, smell and feel.
Ear Psoriasis can appear as dry scales in the ear canal. Psoriasis in the ears can cause scale buildup that blocks the ear canal. This scaling, when combined with normal earwax, can sometimes produce the physical blockage of the external ear canal leading to a temporary decrease in hearing. Psoriasis generally occurs in the external ear canal, not inside the ear or behind the eardrum. It also occurs behind the ear so this area has to be checked to look for the plaques if the diagnosis of psoriasis is considered. Dryness of the skin in the ear, with some scaling is characteristic of psoriasis. Ear psoriasis generally occurs in the external ear canal, not inside the ear or behind the eardrum. Psoriasis of the ears occurs in approximately 18 percent of all patients at some time.
The eardrum is easily damaged. It is best to avoid picking and scratching the affected areas of the ear. Careful cleansing of the ear area can be done using over-the-counter ear-cleaning kits that involve squirting small amounts of fluid into the ear and letting it drain. Plain warm water, followed by a thin layer of mineral oil applied with a cotton swab, is also effective for some people. Wearing wax ear plugs at night helps to keep the affected ear canal from drying out and thereby reduces the severity of ear psoriasis.
Nail Psoriasis can affect both the toenails and fingernails. Psoriasis of the fingernails and toenails is common but can be very difficult to treat. About 50 percent of persons with active psoriasis have psoriatic changes in fingernails and/or toenails. In some instances psoriasis may occur only in the nails and nowhere else on the body. Psoriatic changes in nails range from mild to severe, generally reflecting the extent of psoriatic involvement of the nail plate, nail matrix (tissue from which the nail grows), nail bed (tissue under the nail), and skin at the base of the nail. Damage to the nail bed by the pustular type of psoriasis can result in loss of the nail.
Pitting of the nails may be an early sign of nail psoriasis, although pitting can also occur in other diseases. Sometimes the nails develop a yellowish color and become thick. The nails may crumble easily and be surrounded by inflammation. Nail pitting looks as if a biro tip has pushed a dip into the nail and there may be up to 10 on each affected nail. Having pits in the nails does not mean that the psoriasis is going to behave any differently than if there are no nail pits present. No treatment is available for nail pitting and it is not usually necessary to treat this anyway. Nail pitting does NOT mean that other types of nail problems will arise.
Another possible symptom is detachment of the nail from the nail bed. During this process, the nail becomes whitish in appearance. Sometimes it becomes so badly damaged that it starts to crumble. Nail psoriasis can affect the connective tissue that forms the nails. Other signs of nail psoriasis include the appearance of dark spots resembling oil droplets on the nails, the build-up of flaky skin cells under the nails. Separation or loosening of the nails from their beds results in a condition known as Onycholysis. Onycholysis is when the nail bed develops a build up of keratin causing the nail to appear white when it is viewed from above. It usually starts from the end of the nail and works back. This may be the only sign of psoriasis and may affect only one finger or toenail alone and there may be no other skin rash of psoriasis. Onycholysis may affect only one fingernail and never become more extensive, but in some people it can affect more than one nail. There is no way of predicting this. The nail can lift off from the nail bed and the nail can sometimes be lost. It may or may not grow back normally.
Occasionally the build up of keratin beneath the nails in psoriasis can be very marked and lead to the affected nail becoming thickened and raised. When this happens it is called Onychodystrophy. This can be sore and painful and some sufferers may also find the appearance embarrassing due to comments made by others. The other diagnosis could be a fungal infection of the nail in which case clippings of the crumbly keratin beneath the nail should be sent for culture. Sometimes it can be difficult to tell between the two.
Psoriasis of the nails can resemble other conditions such as chronic infection or inflammation of the nail bed or nail fold. Psoriasis of the toenails can resemble chronic fungal infection of the nails. About one-third of people with nail psoriasis may have a fungal infection, which, if treated, could help their nails to improve. Some treatments used for skin psoriasis also may improve the condition of the nails.
If your nails are affected by psoriasis, try the following:
Trim your nails to reduce the risk of injuring them; trauma can worsen nail psoriasis.
Try soaking affected nails and follow up with moisturizer. Carefully file thickened toenails with an emery board after soaking.
Reduce toenail pressure and friction – which can cause toenails to thicken -- by wearing well-fitted, roomy shoes.
Consider using nail hardeners or artificial nails that can help to improve the appearance of intact nails.
Talk to your physician if deformed nails are a problem for you. They may be surgically removed and replaced with artificial nails.
A person with psoriatic nails should avoid any injury—bumps, scrapes, etc.—that may trigger a worsening of psoriasis, which is a condition called Koebner’s phenomenon. Skin injury. Injury or trauma can make psoriasis worse. Patches of thick, flaky skin may appear following a burn, graze, or rash. If someone is prone to outbreaks of psoriasis, it is important to promptly treat rashes such as those caused by allergies to medication. Otherwise, the rash could lead to a flare-up of psoriasis. The Koebner phenomenon occurs in about 1 in every 4 people with psoriasis. Nail psoriasis is treated by the dermatologist as part of the overall treatment of the disease.
Nail psoriasis is frequently associated with psoriatic arthritis. Certain medications may make psoriasis worse. These include lithium (prescribed to treat bipolar disorder, beta blockers (prescribed for heart problems), anti-malarial drugs, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are available by prescription or over the counter for pain relief. NSAIDs are often used to treat psoriatic arthritis. In such cases, the benefits and risks of treatment need to be carefully assessed. Flare-ups of psoriasis caused by NSAIDs usually respond to treatment.
Ocular psoriasis can cause inflammation of the eye, dryness and discomfort. When psoriasis affects the eyelids, scales may cover lashes. The edges of the eyelids may become red and crusty. If inflamed for long periods, the rims of the lids may turn up or down. If the rim turns down, lashes can rub against the eyeball and cause irritation. In a prolonged ocular episode vision impairment may occur. Ocular symptoms may occur in approximately 10% of psoriasis patients. Ocular involvement is more common in men than in women. It is rare to have involvement of the eye prior to skin involvement of psoriasis.The ophthalmic signs of ocular psoriasis can vary widely, including Blepharitis, Conjunctivitis, Uveitis and Iritis. There have been reported cases of secondary corneal involvement resulting in keratitis.
Blepharitis is the most prevalent ocular occurrence in psoriasis. Erythema, edema, and psoriatic plaques may develop. Blepharitis is a common inflammatory ocular condition that affects the eyelids. It usually causes burning, itching, and irritation of the lids. Other common symptoms include sandy, itchy eyes, red and/or swollen eyelids, crusty, flaky skin on the eyelids, and dandruff. In severe cases, this ocular condition may also cause sties, irritation, and inflammation of the cornea leading to keratitis and conjunctiva (conjunctivitis). Blepharitis, usually a chronic problem, can be controlled with extra attention to lid hygiene. However, it may also be caused by an infection, which would require treatment with a prescription medication. The key to controlling blepharitis is to keep the eyelids and eye lashes clean. Remember to remove all mascara and make-up before going to bed.
Ocular psoriatic conjunctivitis usually occurs in association with eyelid margin involvement of a psoriasis episode. Psoriatic plaques can extend from the lid onto the conjunctiva. Conjunctivitis, also known as pinkeye, is an inflammation of the conjunctiva, the thin, clear tissue that lies over the white part of the eye and lines the inside of the eyelid. Conjunctivitis is caused by viruses, bacteria, irritants such as shampoos, dirt, smoke, and pool chlorine, and allergies such as dust, pollen, or an allergy specific to contact lens wearers. The symptoms of conjunctivitis differ based on the cause of the inflammation, but may include redness in the white of the eye or inner eyelid, increased amount of tears, a thick yellow discharge that crusts over the eyelashes, especially after sleep, green or white discharge from the eye, an itchy or burning sensation in the eyes, blurred vision and/or an increased sensitivity to light.
Uveitis and iritis frequently arise as a complication of psoriatic arthritis or lupus, in which the body's immune system attacks its own healthy tissue.
Uveitis is an inflammation of the uvea, the middle layer of the eye's surface. The uvea includes the iris, the colored area at the front of the eye. When uveitis is localized at the front of the eye, it's called iritis. Iritis is an inflammation of the iris, a part of the eye. Symptoms include eye pain, sensitivity to light, and/or blurry vision and are often confused with the symptoms of conjunctivitis. Uveitis may affect only the fluid that fills the eye, but may also affect the small blood vessels behind the retina. Symptoms of uveitis can include: redness in the eye, sensitivity to light, blurred vision, pain in the eye or "floaters" in the field-of-vision. Early detection and treatment is of the utmost importance. Untreated uveitis can cause irreversible damage to the delicate eye tissue, and it represents the third most common cause of preventable blindness in the nation.Keratitis is one of the more serious conditions, which may occur in relation to ocular psoriasis. Keratitis is a term used to cover a range of ocular conditions where there is infection or inflammation of the cornea. This condition may result in severe eye pain, blurry vision, and sensitivity to light. Medical evaluation and treatment of keratitis is absolutely essential. Minor corneal infections are commonly treated with anti-bacterial or anti-fungal eye drops. If the problem is more severe, a person may receive more intensive antibiotic treatment to eliminate the infection and may even require steroid eye drops to reduce inflammation. Corneal involvement with ocular psoriasis is relatively rare. It usually occurs as a secondary to eyelid or conjunctival complications, such as dryness, trichiasis, or exposure.
Ocular psoriasis shares many similar symptoms to ocular rosacea. Ocular rosacea can cause a persistent burning or gritty feeling in the eyes. For others, ocular rosacea manifests itself as inflamed and swollen eyelids with small-inflamed bumps, eyelashes that may fall out, compounded by bloodshot eyes. The most frequent signs, which may never progress to a more severe condition, are chronically inflamed margins of the eyelids with scales and crusts. Pain and sensitivity to light may be present. The ocular complications are independent of the severity of facial rosacea.
