Types of Psoriasis – FLEXURAL/INTERTRIGINOUS (INVERSE PSORIASIS) and GENITAL PSORIASIS

blog-20

Inverse psoriasis

 also known as flexural or intertriginous psoriasis is a rare form of psoriasis that occurs in the flexural skin folds. Plaque psoriasis is most commonly found on the trunk and extensor surfaces of the body, such as the knees, elbows, sacral (lower back) area, and scalp whereas Inverse psoriasis is found in the folds of the axilla (armpits), submammary (breast) folds, and groin (inguinal) and buttock folds. It can occur in any area where two skin surfaces meet. The inguinal fold is the most commonly affected area, followed by the axilla and the external genitalia. The skin at the inverse body sites differs from skin at extensor sites with less epidermal keratinization (thinner skin) and more sweat glands. The most evident difference between classical plaque-type psoriasis and inverse psoriasis is the lack of, or less, scaling. The lesions are usually well demarcated, erythematous (red), and are often shiny, appear moist, weepy and fissured. The irritation may be increased in inverse psoriasis as a result of the rubbing and sweating involved in the skin folds. 1, 2   

Approximately 3–7% of psoriasis patients present with inverse psoriasis and patients with palmar psoriasis have a greater chance of having inverse psoriasis as compared with plaque psoriasis. In one study of 170 psoriasis patients with palmar involvement, 5.3 times more patients had inverse psoriasis than patients with plaque psoriasis. Development of inverse psoriasis has been reported as a paradoxical side effect to treatment with infliximab for Crohn’s disease and hidradenitis suppurativa. Inverse psoriasis has been observed to be more common in the obese population possibly due to the rubbing of the skin folds. 1, 2

Inverse psoriasis affecting the genitalia seems to be underreported and undertreated; and approximately 35% patients with genital psoriasis never speak to their physician about their genital lesions. Nearly 70% of Physicians do not offer treatment for genital lesions. 3

Flexural Psoriasis 3

A study on the quality of life and sexual life in 487 patients with genital psoriasis concluded that3:

  • patients with genital lesions report even significantly worse quality of life than patients without genital lesions;
  • sexual distress and dysfunction are particularly prominent in women;
  • sexual distress is especially high when genital skin is affected;
  • the attention given to possible sexual problems in the psoriasis population by healthcare professionals is perceived as insufficient by patients.     

Flexural Psoriasis 2

Results of several questionnaire-based surveys show that involvement of the genital skin region occurs in 29–40% of patients with psoriasis. The genital area may frequently be involved in cases of inverse psoriasis. Of 48 patients with inverse psoriasis, the external genitalia were involved in 38 (79.2%). 4

Flexural Psoriasis 1

In another report researchers stated that patients with genital psoriasis have significantly worse quality of life (QoL) scores compared with patients without genital lesions. In addition, numerous patients with psoriasis have sexual dysfunction. Between 25–40% of patients reported a decline of sexual activity since the onset of psoriasis, mainly due to diminished sexual desire, embarrassment of physical appearance and inconvenience caused by scaliness of the skin or topical therapy. Particularly in women with genital psoriasis, sexual distress is higher and sexual function is more significantly impaired compared to those without genital lesions. 4

Inverse psoriasis is often misdiagnosed for bacterial or fungal intertrigo. Intertrigo is inflammation of opposed skin folds caused by skin-on-skin friction that presents as erythematous, macerated (moist, broken, soft skin) plaques. Secondary bacterial and fungal infections are common because the moist, denuded skin provides an ideal environment for growth of microorganisms. Candida is the most common fungal organism associated with intertrigo. Intertriginous candidiasis also presents as well demarcated, erythematous patches but with tell tale satellite papules or pustules at the periphery (around the edges). Candida, Staphylococcus aureus and Malassezia furfur have been shown to colonize psoriatic skin lesions so diagnosis for flexural psoriasis is sometimes not easy. Candida species have been isolated from the skin of 15% of psoriasis patients compared to only 4% in the control group. 5, 6 However, some studies have also suggested that Candida is not commonly found in psoriatic lesions of inverse of genital psoriasis.

Application of topical treatment in the intertriginous areas is considered as treatment under occlusion due to enhanced hydration and increased skin absorption. However, the inverse areas are considered more sensitive and prone to side effects from topical steroids (i.e. due to thinner skin at these locations). 2

 

REFERENCES

  1. Syed Z. U. and Khachemoune A.; Inverse Psoriasis Case Presentation and Review; Am J Clin Dermatol 2011; 12 (2): 1-4 1175-0561/11/0002-0001/$49.95/0
  2. Silje Haukali Omland  and Robert Gniadecki; Psoriasis inversa: A separate identity or a variant of psoriasis vulgaris?; Clinics in Dermatology (2015) 33, 456–461
  3. Meeuwi  K.A.P. et al.; Genital Psoriasis: A Systematic Literature Review on this Hidden Skin Disease;  Acta Derm Venereol 2011; 91: 5–11
  4. Meeuwis KAP, et al.; Genital Psoriasis Awareness Program: Physical and Psychological Care for Patients with Genital Psoriasis. Acta Derm Venereol. 2015, 95, 211–216
  5. Wilmer E.N. et al.; Resistant “Candidal Intertrigo” ”: Could Inverse Psoriasis Be the True Culprit?; doi: 10.3122/jabfm.2013.02.120210
  6. Taheri Sarvtin, et al.;. Evaluation of candidal colonization and specific humoral responses against Candida albicans in patients with psoriasis. International Journal of Dermatology. Dec2014,Vol.53Issue12, pe555-e560. 6p.

PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – PART 3

blog-6

The last in our 3 part series addressing psychological and psychiatric disorders associated with psoriasis.

   Psychological and Psychiatric Disorders –

   Sleep Disorders

   Somatoform Disorders

   Substance dependence of abuse

1, 2, 3

Sleep Disorders

It is thought that psoriasis has a direct effect on the development of sleep disorders due to the cutaneous (skin) symptoms of the condition. The skin is the primary circadian mediator of core body temperature (CBT), and a decrease in CBT in the late evening is an important mechanism for sleep initiation. Psoriasis has been associated with problems with thermoregulation and researchers have indicated that the reduced ability to dissipate heat is one factor in the inability to initiate sleep. Pruritus (itch) is another contributor to sleep disturbance and it is also regulated by circadian mechanisms. The threshold for pruritus is lowered in the evening due to complex circadian-mediated factors such as lower cortisol levels, decreased epidermal barrier function, and increased distal-to-proximal (distant limbs-to-body centre) gradient in skin temperature. Thus pruritus in psoriasis typically manifests or exacerbates mainly in the evening and worsens at night. 4,5,6

 so-tired-1440121-1600x1200

The inflammatory biological mechanism(s) that lead to initiation and exacerbation of psoriasis, also contribute to the development of systemic diseases e.g. depressive disease, hypertension (blood pressure), adverse cardiac events, diabetes, metabolic syndrome and obesity. All of these conditions are known to indirectly give rise to sleep-disordered breathing. The heightened pro-inflammatory state in conditions such as obstructive sleep apnoea syndrome (OSAS) and insomnia could in turn lead to exacerbations of psoriasis.4,5,6

A systematic review of the literature on the relationship between psoriasis, PsA, and formal sleep disorders identified an increased prevalence of OSAS with a 36-81% prevalence in psoriasis versus 2% for women and 4% for men in the general population.4,5  In one study researchers found that some patients with chronic psoriasis and concurrent OSAS showed improvement of their psoriatic lesions while on nasal continuous positive airway pressure (CPAP).6 OSAS leads to severe physical and, possibly, psychological stress to the body, e.g., by hypoxemia (low blood oxygen levels), increased blood pressure, tachycardia (fast or irregular heart rate), sleep fragmentation, reduction of deep sleep, reduction of REM sleep, hypersomnia (excessive sleepiness), and insomnia. It is known that OSAS also dysregulates the function of the patient’s autonomic nervous system and hormone system. It is felt that this might alter the homeostasis of the immune neuroendocrine network in the skin and may cause the initiation of psoriasis in the genetically predisposed individuals.4,5,6

Somatoform Disorders – psychosomatic symptoms

Somatization is the manifestation of psychological distress by the presentation of bodily symptoms such as feeling nausea due to anxiety, stress headaches, falling ill after a trauma and inability to cope with a disease. 

Patients with psoriasis exhibit higher scores of hypochondriasis, hysteria, and somatization. As previously exposed hypochondriasis and hysteria may be connected with specific personality traits of patients with psoriasis of late-onset. Psychosomatic factors, namely stressful life events, lack of social support, and attachment insecurity, may explain why patients with psoriasis have greater scores of somatization. Moreover, the presence of depression in psoriasis may modulate itch perception and then exacerbate symptoms of pruritus.7 (Refer to Part 1 of this series) A systematic review of the psychosocial burden of psoriasis found that social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity. Some psoriasis patients had, even when their lesions were small and mild, levels of stress and loss of confidence that was not in keeping with the severity of their condition – which leads to the conclusion that they had maladaptive coping mechanisms in play e.g. self blame, blaming parents, social phobia, avoidance behaviours, substance and alcohol abuse etc. 9

Substance – Dependence of Abuse

In our previous blog Psoriasis and Alcohol (ethanol), we stated that patients with psoriasis experience considerable emotional distress, depression and social isolation due to the visibility of skin lesions, especially when the lesions are widespread and severe. Whilst it would be demeaning to state that all psoriasis patients with mild to severe psoriasis suffer from alcoholism, it has been confirmed in several Quality of Life studies that the percentage of psoriasis patients who admit to having a drinking problem may be as high as 32%. Research indicates that men are more likely to use alcohol excessively as a coping mechanism with the psychosocial burden of psoriasis. Consequently they are at a higher risk of developing depression – with the alcohol misuse and psoriasis as underlying causes. 4 Another study indicated that for women, excessive alcohol intake above a certain threshold (?30.0 g/d), may be associated with a significantly increased risk of Psoriatic Arthritis (PsA).5

have-a-drink-1-1510449-640x480-1

Alcohol is known to inhibit inflammation and immune responses; however acute and chronic alcohol consumption have opposite effects on inflammatory cell activation. Results indicate that acute alcohol exposure is inhibitory, whereas chronic alcohol exposure leads to an increase in inflammatory cell responses.6

Research has confirmed that alcoholics are more susceptible to infections, as streptococcal infections are trigger factors for psoriasis, this increased susceptibility may be involved in the onset and progress of the disease. It is also known that measurable quantities of ingested ethanol are secreted through human skin. Transdermal ethanol derives from two processes: active secretion by eccrine glands, primarily sweat glands, and passive diffusion through the lipid layers of the skin. Ethanol disrupts the dermal barrier enhancing skin permeability for numerous chemicals and increases the solubility of penetrating chemical compounds.6

Research into the the use of illicit drugs and psoriasis is extremely limited. Methylenedioxymethamphetamine (MDMA), also called Ecstasy, has been reported to initiate Guttate Psoriasis. The researchers theorized that “While MDMA [the main ingredient in ecstasy] is taken for its psychomimetic effect, pharmacologically it increases the level of noradrenaline, serotonin and dopamine by inhibiting the reuptake mechanism. It is known that Patients with psoriasis already have increased levels of noradrenaline.”7 There are also anecdotal stories on support websites where psoriasis sufferers have spoken about the exacerbation of their psoriasis with the use of “meth” (Methamphetamine, Ice). Within our clinic we have had several patients whose psoriasis was initiated and exacerbated by the use of cannabis (street not medicinal), once they ceased the use of cannabis their psoriasis resolved. As long as they did not use cannabis they remained free of any psoriatic lesions.

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Brenaut E. et al.; Alcohol consumption and psoriasis: a systematic literature review. J Eur Acad Dermatol Venerol. 2013 Aug;27 Suppl 3:30-5. doi: 10.1111/jdv.12164.
  • Shaowei Wu et al.; Alcohol Intake and Risk of Incident Psoriatic Arthritis in Women; J Rheumatol. 2015 May ; 42(5): 835–840. doi:10.3899/jrheum.140808.
  • Farkas A, Kemény L.; Psoriasis and alcohol: is cutaneous ethanol one of the missing links?; • British Journal of Dermatology 2010 162, pp711–716
  • Tan B., Foley P.; Guttate psoriasis following Ecstasy ingestion; Australasian Journal of Dermatology45(3):167-9 September 2004?

PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – PART 2

blog-5

WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

 CHART 1: Comorbidities Associated with Psoriasis

    Psychological and Psychiatric Disorders –

   Personality Traits and Personality Disorders

   Schizophrenia and other psychoses

   Sexual Dysfunction

1, 2, 3

Personality Traits and Personality Disorders

It has also been proposed by a number of researchers that patients with skin disease usually present with certain psychological traits that makes them vulnerable to stress. Although a specific personality structure for psoriasis patients has not yet been defined, psoriasis patients are reported to have more obsessive compulsive, avoidant, schizoid and passive-aggressive properties than healthy controls, however the research surrounding personality and psoriasis is still controversial. 4

The term personality represents the different behavioural styles that individuals present in their habitual habitats or environments.4 In one study of male psoriasis patients and a control group the psoriasis group scored significantly higher scores than the control group in Extravagance (NS3), Disorderliness (NS4), Novelty Seeking (NS), Anticipatory Worry (HA1), Shyness with Strangers (HA3), Fatigability and asthenia – weakness – lack of energy and strength (HA4), Harm Avoidance (HA), Dependence (RD3), Reward Dependence (RD), Self-forgetfulness (ST1), Transpersonal Identification (ST2), Spiritual Acceptance (ST3) and Self-Transcendence – the ability to focus attention on doing something for the sake of others (ST).5

Another study found that the severity of pruritus (itch) and the severity of psoriasis was associated with significantly higher scores for depression and anxiety, and showed the personality traits of somatic anxiety (physical reactions to anxiety e.g. sweating, nausea etc.), embitterment, mistrust, and physical trait aggressiveness. However, the researchers also found that the severity of itch was not associated with the severity of psoriasis from a PASI score perspective. In fact they found that there was a higher severity of itch reported in 30% of psoriasis patients in which the greater majority of these had very few lesions.6

Psoriasis Patients often report felt or perceived stigma, referring to the negative attitudes and responses that they perceive to be present in society and the sense of shame and fear of being discriminated against because of being ‘flawed’ due to the physical appearance of their lesions. The actual experiences of stigmatization range from –  people showing disgust or aversion, making negative comments or totally avoiding contact.6

Stigmatization contributes considerably to disability, depression and reduced quality of life in psoriasis patients, and can be considered a stressor. As distress can be a trigger for psoriasis exacerbation, this can become a vicious self-perpetuating cycle. The Type D personality has previously been associated with increased risk of cardiovascular morbidity and mortality and impaired health behaviour e.g. smoking and alcohol dependence, which are both frequently reported in psoriasis. The two main features – SI (social inhibition) and NA (negative affectivity) – may both increase the impact of perceived stigmatization. SI refers to conscious or subconscious avoidance of a situation or social interaction because of the possibility of others disapproving of their feelings or expressions.  Whilst NA refers to negative emotions, including anger, contempt, disgust, guilt, and fear, and nervousness. Furthermore, individuals with high levels of NA may be more likely to perceive social interactions as negative, due to the associated cognitive bias to negative feedback. In one study researchers found that perceived stigmatization was particularly predicted by disease impact, as well as by lower age, lower education, greater disease severity and visibility, longer disease duration, higher levels of SI, having a type D personality and being single. 6

The researchers concluded that it seems likely that patients with psoriasis who are prone to feelings of helplessness regarding the disease may also experience a larger impact of psoriasis and magnify negative reactions of others. Type D personality and its subcomponent SI were found to be significant predictors of perceived stigmatization. The fear of disapproval that leads individuals to inhibit emotions or behaviour in SI may explain its relation to perceived stigmatization. They stated that socially inhibited individuals may be more sensitive to the reactions of others and may therefore perceive themselves to be stigmatized more readily. They found that not only was SI in itself, but also the combination of higher levels of SI and NA (type D personality) was a significant predictor of perceived stigmatization, which  corresponded with previous studies that suggested that type D was associated with social impairments. 6

It was suggested that Practitioners should screen for feelings of Stigmatization and related problems, and implement with the patient, targeted interventions that may focus on the impact of the condition on daily life, considering that this was the largest predictor. Therapy, such as Cognitive Behavioural Treatment, which should include social skills training, has shown promise as an intervention treatment. Previous research indicates that it can decrease perceived stigmatization in skin conditions, improve psychological and disease-related outcomes in psoriasis patients, and decrease feelings of helplessness, which shows high correlations with disease severity and impact. 6

It is extremely important that psoriasis sufferers do not cut themselves off from social interactions and it is highly recommended that they join a support group that is not only internet based but one that meets socially on a face to face basis. 

frustrated-1439244-640x480

Schizophrenia and other psychoses

 The psychiatric morbidity in psoriasis is considered an important indicator of the disability experienced by the patient than the dermatologic aspects of the disorder, sometimes more so than the physical aspect of the lesions. Some studies have found a possible connection between psoriasis and psychosis, including schizophrenia. Schizophrenia is a polygenic (involvement of 2 or more genes), multifactorial disorder and recent neuroanatomical and neurobiological being related to the nervous system as well as environmental and genetic studies have suggested that inflammatory pathways are also involved in its pathogenesis. Because psoriasis is also considered a state of chronic systemic inflammation involving several genes and is a related immune processes might explain the link between psoriasis and its comorbidities.7

In a systematic review researchers reviewed the published clinical papers on the link between psoriasis and Schizophrenia and other psychoses. The results of the systematic review found that there is some evidence of a relationship between schizophrenia and/or disorders with psychotic features and psoriasis. In one case-controlled study the authors concluded that schizophrenic patients have a higher probability of having a diagnosis of psoriasis whilst other studies highlighted that psoriasis patients have a higher risk of having schizophrenic traits. The main characteristics of schizoid character are social isolation, intimacy avoidance and restricted affections. Although for a long time was considered that a schizoid character was related to schizophrenia, this has been found to be not always true. Nevertheless, schizoids may be more susceptible to psychosis. This personality shares with schizophrenia, although with its own subtleties, the problem of the distinction between the “self” and the “other”. Several studies have reported on the occurrence of psoriasis in schizophrenia patients being treated with cyclosporine A and olanzapine. And other schizophrenia patients with existing psoriasis found that treatment with haloperidol and levomepromazine actually also improved the patients psoriasis.7

 For some psoriasis patients it was found that whilst they were experiencing a worsening of their skin lesions their existing psychotic condition also worsened, and as their skin improved so too did their psychotic condition.7 The hypothesis is that psoriasis, schizophrenia and other psychotic conditions share similar pathways.

Sexual Dysfunction

Sexual health is an important part of general health and sexual dysfunctions can negatively affect self-esteem, confidence and interpersonal relationships. The impact of psoriasis upon sexual function seems to be substantial and it has a significant impact in quality of life. One study found that when compared to a control group, the psoriasis group showed significant impairment of all the components of sexual function: sexual interest, sexual arousal, orgasm, erection and sexual satisfaction. “Sexual interest” and “global sexual satisfaction” were the most negatively affected components. Male patients with psoriasis showed an increase in erectile dysfunction compared to controls. The prevalence of sexual dysfunction was 53.7% in patients with psoriasis vs. 17.5% in the healthy control group. The researchers also found that psoriasis lesions on the genitals, buttocks, abdomen or lumbar (back) region were significantly linked to sexual dysfunction and those psoriasis patients with sexual dysfunction had higher scores for depression (32.5%) and anxiety (50%). 9

Certain components of sexual response, such as sexual interest, depend primarily on psychological factors, and are impaired by conditions such as anxiety and depression, while others such as erection and orgasm can be affected by psychological and physical causes.

It has also been suggested that the sexual dysfunctions might not be as a direct result of depression, but rather of low self-esteem or other emotional problems. As sexual impairment in psoriasis patients was seen to occur in all components of the sexual response, the researchers concluded that this suggested that sexual dysfunction in psoriasis must be a consequence of several combined factors.9,10

If you have a concern about depression, bipolar, schizophrenia or sexual dysfunction please discuss your concerns with your General Practitioner.

Read also PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – Part 1

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Martín-Brufau R. et al.; Personality in Patients with Psoriasis; Chapter 11 rfrom the book Psoriasis Downloaded from: http://www.intechopen.com/books/psoriasis
  • Ak M. et al.; Temperament and character properties of male psoriasis patients; Journal of Health Psychology; pg 1-8; 2011; DOI: 10.1177/1359105311423863
  • Remröd ;  Pruritus in Psoriasis: A Study of Personality Traits, Depression and Anxiety; Acta Derm Venereol 2015; 95: 439–443;
  • Ferreira BR, Pio Abreu JL and Figueiredo A.; Psoriasis, Schizophrenia and Disorders with Psychotic Features: Are They Linked?; J Schizophr Res. 2015;2(1): 1006.
  • Molina-Leyva A. et al.; Distribution pattern of psoriasis, anxiety and depression as possible causes of sexual dysfunction in patients with moderate to severe psoriasis; An Bras Dermatol. 2015;90(3):338-45
  • Sarbu, Maria Isabela; Tampa, Mircea; Sarbu, Alexandra Elenda; and Georgescu, Simona Roxana (2014) “Sexual Dysfunctions in Psoriatic Patients,” Journal of Mind and Medical Sciences: Vol. 1: Iss. 1, Article 5.

PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – Part 1

blog-7

WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

CHART 1: Comorbidities Associated with Psoriasis

Psychological and Psychiatric Disorders – Depression

anxiety

Suicide

Addiction

1, 2, 3

Psychophysiologic disorders are associated with skin conditions, such as psoriasis, that are frequently precipitated or exacerbated by emotional stress. For many sufferers of psoriasis associated depression, anxiety, addictions to alcohol etc. and even suicidal thoughts are common.

As far back as the 1940s and 1950s researchers explored the relationship between emotions and psoriasis theorizing various ideas such as “chronic psoriasis is often linked with deeply repressed emotional conflicts”, that “nervous exhaustion” may play a role in the causation and aggravation of the disease”, and that “in emotionally maladjusted individuals the psychological factor may ‘take charge’ of the psoriasis and determine its onset, persistence and relapses.” 1  

Since the 1970’s numerous studies have been conducted by researchers in the bid to understand the subtleties involved in the interplay between mental and emotional stresses, anxieties and depression with psoriasis. Research in the 2000s has greatly defined the psychological and psychiatric disorders associated with psoriasis, they include:-

Anxiety Disorders 1, 2

  • Acute stress disorder–anxiety symptoms occur immediately following a trauma, but are short-lived.
  • Adjustment disorder with anxious features–anxiety symptoms in relation to a major life-changing event – like getting married or moving to another city. Symptoms generally start within three months of the stressful event and occur for six months or less.
  • Substance-induced anxiety disorder– generally resolves when the substance is discontinued or when withdrawal from the substance is over.

INCLUDING:

  • Panic Disorder (With Or Without Agoraphobia) – consists of severe, immediate anxiety symptoms (a panic attack) due to a broad range of fears, such as of open spaces, public transportation or about being trapped or about being safe when outside the home, as well as the worry over having another panic attack.
  • Generalized anxiety disorder (GAD)– is characterized by excessive, exaggerated anxiety and worry about everyday life events with no obvious reasons for worry. People with symptoms of generalized anxiety disorder tend to always expect disaster and constantly worry about health, money, family, work, or school, which is often totally unrealistic or out of proportion for the situation. Day to day life becomes a constant state of worry, fear, and dread.
  • Social Anxiety Disorder (SAD)

       People with social anxiety disorder (sometimes called “social phobia”) have a marked fear of social or performance situations in which they expect to            feel embarrassed, judged, rejected, or fearful of offending others.

       Social anxiety disorder symptoms include:

  •   Feeling highly anxious about being with other people and having a hard time talking to them
  •   Feeling very self-conscious in front of other people and worried about feeling humiliated, embarrassed, or rejected, or fearful of                                         offending others
  •   Being very afraid that other people will judge them
  •   Worrying for days or weeks before an event where other people will be
  •   Staying away from places where there are other people
  •   Having a hard time making friends and keeping friends
  •   Blushing, sweating, or trembling around other people
  •    Feeling nauseous or sick to your stomach when other people are around
  • Obsessive-compulsive disorder (OCD) – anxiety symptoms are in the form of intrusive, obsessive thoughts and compulsive behaviors (or mental acts). OCD is considered a chronic type of anxiety disorder.
  • Post traumatic stress disorder (PTSD)– anxiety symptoms that occur after a trauma and are long-term in nature.
  • Social phobia, also referred to as Social Anxiety Disorder – anxiety symptoms occur in social or performance situations and stem from the fear of being humiliated or embarrassed.
  • Specific phobia or a simple phobia– anxiety symptoms occur around a specific object or situation which results in avoidance.

Psoriasis sufferers have reported more stressful life events in comparison with control subjects. The link between psoriasis and anxiety can be analyzed in two ways – anxiety can lead to psoriasis and psoriasis can lead to anxiety. Also research has confirmed that an increase in severity of psoriasis leads to an increasing frequency of anxiety. The magnitude of this anxiety may be influenced by variables of disease e.g. severity, distribution of lesions, duration of condition and nail and joint involvement. Likewise it should also be noted that variables of life e.g. age, gender and marital status influence psoriasis associated anxiety and depression. 3

Eating Disorders – Obesity 4,5

Increasing evidence suggests that patients with psoriasis may be more obese compared with the general population. Although the exact mechanism underlying the association between psoriasis and obesity is uncertain, researchers have theorized that adipocytes (fat cells) as a rich source of pro-inflammatory cytokines may exacerbate psoriasis.

Which Comes First? Obesity or Psoriasis?

The answer to this question remains unknown as the precise mechanism underlying the association between psoriasis and obesity remains elusive. However, two longitudinal prospective cohort studies found weight gain or obesity; particularly from the age of 18 years was a risk for developing psoriasis in women. It still bust be noted that not all psoriasis sufferers are obese and not all obese individuals develop psoriasi

Mood Disorders (Depressive Disorders and Bipolar Disorder)6

Research has recently considered whether psoriasis is a psycho-dermatological disorder.

A psycho-dermatological disorder is a condition that involves an interaction between the nervous and the integumentary (skin) system. Psoriasis has been found to be associated with clinical depression commonly known as major depression through an immunological phenomenon. Research has shown the possibility of a relationship between common forms of psoriasis and major depressive disorder and an increase in stress and depressive symptoms has been found to have a significant statistical correlation with an increase in psoriasis flare-ups and pruritus severity along with a more clinically disfiguring disease. In addition, studies have shown that a decrease in depression/depressive symptoms due to medication or therapy is often associated with a decrease in psoriasis severity and vice versa. Other research has found that many inflammatory markers and cytokines which are released during depression are also released during psoriasis.

Research into depression has found that it leads to an increase in the concentration of proinflammatory cytokines systemically in patients afflicted with the disease, and that these same proinflammatory cytokines migrate towards the epidermis (skin) and cause psoriatic lesions in susceptible patients, either increasing psoriasis severity or potentially leading to its initiation or a flare up. Other research has found that mutations in genes related to psoriasis cause an increase in the same proinflammatory cytokines. These cytokines can cause HPA axis (hypothalamic–pituitary–adrenal axis) hyperactivity which is observed in major depressive disorder and that this then disturbs the negative feedback inhibition of circulating corticosteroids on the said axis and leads to lower serotonergic (5-HT) neurotransmitter levels, thus leading to a depressive disorder. READ ALSO OUR PREVIOUS BLOG: – STRESS, ANXIETY,

DEPRESSION AND PSORIASIS

Bipolar Disorders

Bipolar is a significant, serious and debilitating mood disorder. If it is not bad enough that a person may have this condition, Lithium, one of the most commonly prescribed psychotropic medications for this condition, has been associated with a wide range of cutaneous side effects including the initiation and exacerbation of psoriasis. In the general population prevalence of bipolar is estimated to be 3%, the prevalence of psoriasis varies from 1–5% in Western Countries; approximately 2% of these patients will suffer from bipolar.

Lithium, which has been in use for the treatment of bipolar for over 50 years, has a long history of systemic adverse effects, including the skin. The reported prevalence of the cutaneous side effects varies from 3% to 45% in different studies. Acne/acneiform and psoriasiform rashes are among the major cutaneous adverse effects of lithium and these may result in noncompliance. It should be noted; however, not all the patients with pre-existing psoriasis show flares while they are on lithium treatment. Male patients who take lithium are more likely to develop cutaneous reactions than their female counterparts.7

 Look out for our next edition on this topic –  PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – Part 2 

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Toussirot É. Et al.; Relationships between adipose tissue and psoriasis, with or without arthritis; Frontiers in Immunology; August 2014 | Volume 5 | Article 368 ; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129363/pdf/fimmu-05-00368.pdf
  • Aldeen, et al; Obesity and Psoriasis: Can Bariatric Surgery Trigger Psoriasis?; J Clin Exp Dermatol Res 2015, 6:6 http://dx.doi.org/http://dx.doi.org/ 10.4172/2155-9554.1000305
  • Tohid H. et al.; Major Depression and Psoriasis: A Psychodermatological Phenomenon; Skin Pharmacol Physiol 2016;29:220–230 DOI: 10.1159/000448122

 

PSORIASIS and COMORBIDITIES – PSORIATIC ARTHRITIS

blog-1

WHAT IS COMORBIDITY?

 Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

Psoriatic Arthritis

Spondyloarthropathies

CHART 1: Comorbidities Associated with Psoriasis 1,2,3

Psoriatic arthritis (PsA) is an inflammatory arthropathy, which is associated with psoriasis in approximately 25% of patients. It is characterized by stiffness, pain, swelling, and tenderness of the joints as well as the surrounding ligaments and tendons. It affects men and women equally and typically presents at the age of 30 to 50 years. Skin lesions usually precedes the onset of PsA by an average of 10 years in the majority of patients but 14– 21% of patients with PsA develop symptoms of arthritis prior to the development of skin lesions.4

human_hand_bones-en The Foot

                  The Hand                                                                                             The Foot

The presentation of PsA is variable and can range from a mild, non-destructive arthritis to a severe, debilitating, erosive arthropathy.

There are various classifications for PsA:-

• Monoarthritis of the large joints – inflammation and arthritis in one joint.

PsN 1 Finger

          Swelling evident in the joint between the Intermediate and Proximal Phalanges in the index finger

  • Distal interphalangeal arthritis – affecting the joint between the Distal and Proximal phalanges.
  • Spondyloarthritis – affecting the spine and, in some people, the joints of the arms and legs.

Symmetrical deforming polyarthropathy – similar to that of rheumatoid arthritis

PsN all Distal Joints

Deformity of the Distal interphalangeal joints with varying degrees of severity seen across all of the fingers from severe to mild.

If PsA is left untreated, a percentage of patients may develop chronic inflammation with progressive deforming joint damage which leads to severe physical limitations and disability. So it is very important for a patient with psoriasis who is experiencing joint swelling or pain to be reviewed by a Rheumatologist as soon as possible. However, as there is no specific test for PsA, the diagnosis of PsA is based on clinical judgement. The main aspect is the absence of rheumatoid factor (91-94%), this key finding together with the specific presentation of joint pain and inflammation plus the presence of psoriasis skin lesions all combine to lead the Practitioner and the Rheumatologist to diagnose PsA. X-rays may aid diagnosis and can show the extent and location of joint damage. Other types of scans such as MRI or CT scans can also be used to look at the joints in more detail.

In many patients articular patterns change or overlap in time. Enthesitis, inflammation at the sites where tendons or ligaments insert into the bone, may occur at any site, but more commonly at the insertion sites of the plantar fascia (the fibrous band of tissue (fascia) connecting the heel bone to the base of the toe bones), the Achilles tendons, and ligamentous attachments to the ribs, spine, and pelvis. PsA is unusual in that it can affect joints on only one finger or toe, several joint on one side or on affect joints on both sides of the body. PsA symptoms often resemble those of rheumatoid arthritis. Both diseases cause the joints to become inflammed, painful, swollen and warm to the touch.4

The most common symptoms are:-

  • Swollen fingers and/or toes.  PsA can cause a painful, sausage-like swelling of the fingers and/or toes. Swelling and deformities in the hands and feet before having significant joint symptoms may occur.

  • Foot pain. Psoriatic arthritis can also cause pain at the points where tendons and ligaments attach to the bones — especially at the back of the heel or in the sole of the foot.
  • Lower back pain.Some sufferers develop a condition called spondylitis as a result of PsA which causes inflammation of the joints between the vertebrae of the spine and in the joints between your spine and pelvis (sacroiliitis).

Skin lesions in patients with PsA and psoriasis may vary from a mild to a severe presentation and the skin activity is commonly not indicative of the severity of the arthritis symptoms. It is important to note that skin lesions and symptoms normally precede arthritic signs and symptoms in 80% of psoriatic arthritis patients. Whilst simultaneous onset of arthritic and psoriatic symptoms will occur in approximately 13% of patients, only 3% of patients will have joint involvement preceding the development of skin lesions.5

People with PsA often experience pain, stiff joints and muscle weakness and often this is due to lack of use so a regime of light exercise is very important to improve overall health and to keep the joints as flexible as possible. It may be of benefit for people with PsA to consult with an exercise physiologist / remedial therapist who can give advice as the most suitable exercises that are patient specific, including how to get started safely, so that the potential to aggravate the joints are kept to a minimum.

Some of the types of exercise that should be discussed with your physiologist / therapist are:-

  • Aerobic exercises – walking, swimming or gentle water aerobics
  • Muscle-strengthening exercises – light weights
  • Muscle-stretching exercises
  • Hydrotherapy – supervised structured exercises of specific extremities and joints in warm water.

Use of Assistive Devices

An assistive device is a tool or implement that makes a particular function or action easier or possible to perform, e.g.:-

Clothing Aids

  • Velcro on clothes and shoes or elastic shoelaces.
  • Button and zipper hooks.
  • Leg-Up Leg Lifter allows users with limited mobility to avoid having to bend down or hold onto clothing to lift their leg.
  • Long handled shoe horns.

Grooming Aides

  • Fit Combs, brushes and toothbrushes with easier-to-hold handles for ease of use.
  • Or use Long handled brushes and combs that have anti-slip handles.
  • Use a toothpaste dispenser that automatically dispenses a set amount of toothpaste onto a brush.

Bathing and Showering Aides

  • Use a long handled hair washer that can be used to apply shampoo and massage the user’s scalp while reducing strain on the hands, shoulders, or arms.
  • Long handled foot wash brush to assist people with limited access to their feet.
  • Long handled sponge or cloth body washers.
  • Long handled lotion or ointment applicators.

Cooking and Cleaning Aides

  • Finger loop utensils.
  • Oven knob turner.
  • Cut resistance gloves and Finger protector (slicing) guard.
  • Easy glide plastic bag opener.
  • Jar “pop” openers.
  • Tin pull top openers.

Walking Aides

  • Walkers, canes, knee and ankle braces.

Remember there are many websites available where you can purchase any number of assistive devices.

It is important not to lock oneself away and use immobility as an excuse not to socialize. Use group exercise classes to not only improve one’s fitness and mobility but also use the opportunity to talk to other class member’s, or join a support group ….. just the act of talking and sharing can be enough to ensure that you do not become depressed.

 

 

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Lloyd P. et al.; Psoriatic Arthritis: An Update; Hindawi Publishing Corporation Arthritis Volume 2012, Article ID 176298, 6 pages doi:10.1155/2012/176298
  • Gottlieb A.B. et al.; Clinical characteristics of psoriatic arthritis and psoriasis in dermatologists’ offices; Journal of Dermatological Treatment. 2006; 17: 279–287

 

 

Types of Psoriasis – GUTTATE PSORIASIS (GP)

blog-28

Guttate means “drop” in Latin (also known as Teardrop Psoriasis, Raindrop Psoriasis or Psoriasis Exanthematic), and is the second most common type of psoriasis. Guttate psoriasis (GP), is an important clinical variant which occurs more commonly in adolescents and young adults. It is characterized by the sudden onset of widely dispersed small red scaly plaques – 0.2 – 2.0 cm’s in diameter, mainly over the trunk and proximal limbs. The symptoms of GP are numerous small, bright red or salmon coloured, drop-like spots which cover a large portion of the skin. Spots have an abundant fine scaling. The lesions are usually located on the trunk, arms, legs and scalp and spares the face, palms and soles.1

GP represents approximately 2% of psoriasis patients and 30% of guttate patients have a first degree family member with psoriasis 2. Among patients with acute guttate psoriasis, 56–98% experienced a streptococcal infection (e.g. tonsillitis, viral respiratory infections, laryngitis etc.) within a 2-3 weeks period prior to the eruption and, it is theorized that psoriasis may be induced in susceptible individuals by streptococcal superantigens. In children perianal streptococcal infections (or chronic pruritus of the anus) have also been associated with GP 3.

Because some cases of GP in childhood may be triggered or exacerbated by streptococcal pharyngeal infections, the role of tonsillectomy as a treatment option in severe refractory GP has been studied. However, the results remain controversial and at best non conclusive. In a Cochrane review the conclusion that tonsillectomy may be a successful treatment modality in selected patients with recalcitrant GP is suspect due to the fact that many of the studies were not of a high enough standard for the conclusions to be definitive.5 A study in 2012 which was a blind study found that patients with chronic GP and a history of disease exacerbation in association with sore throat, generally improved after a tonsillectomy.6

Many other infectious agents have also been implicated, although the exact frequency of GP associated with these infections/diseases is unknown.

They include the following:

  • Bacteria – other than Staphylococcus aureus – Enterococcus faecalis, Escherichia coli, Pseudomonas and Proteus species, or the bacterium implicated in duodenal ulceration, Helicobacter pylori.5
  • Fungi – Malassezia, Candida
  • Viruses – Flu, Human papillomavirus (HPV), varicella-zoster virus, human endogenous retroviruses (HERVs) e.g. cytomegalovirus and vaccinations 7.
  • Drugs (including biologic agents) sometimes cause a guttate-type flare.

The most commonly implicated drugs in association with either the initiation or exacerbation of GP include lithium, beta-blockers, antimalarial, and non steroidal anti-inflammatories. 

Immunomodulatory drugs such as infliximab, etanercept, imatinib, and adalimumab have also been reported to initiate GP. The Koebner Phenomenon e.g. tattoos, insect bites scratches etc. can trigger GP.

Approximately 70% of patients with GP will go on to develop chronic plaque psoriasis within a 10 year time frame.

For more information read Our BLOG “PSORIASIS – THE RELATIONSHIP WITH VIRAL, BACTERIAL AND FUNGAL INFECTIONS?”

Guttate with fine scale                        Guttate with no scale

Figure 1. Scattered drop like lesions                                Figure 2. Reddish – scattered drop like lesions

ranging from 0.5 to 2.0 cm, with slight scale.                   ranging from 0.2 to 1.0 cm with no scale.

Coalesing Guttate 4                     Coalesing Guttate 3

Figure 3. Note the fine scale and the                              Figure 4. Note the fine scale and the complete

coalescing (merging) of the lesions.                               merging of the lesions.

Coalesing Guttate                      Coalesing Guttate 2

Figure 5. Reddish lesions – where the                                      Figure 6. Salmon pink lesions – where the             

majority of the lesions have merged.                                       majority of the lesions have merged.

REFERENCES

  • Zangeneh F.Z., Shooshtary F.S.; Psoriasis — Types, Causes and Medication – Chapter 1; http://cdn.intechopen.com/pdfs-wm/44173.pdf
  • Mallbris et al.: Psoriasis Phenotype at Disease Onset: Clinical Characterization of 400 Adult Cases; Journal of Investigative Dermatology; Volume 124, Issue 3, March 2005, Pages 499–504
  • Honig J.; Guttate psoriasis associated with perianal streptococcal disease; Clinical and laboratory observations The Journal of Pediatrics December 1988
  • Telfer NR,Chalmers RJ, Whale K, Colman G. The role of streptococcal infection in the initiation of guttate psoriasis. Archives of Dermatology 1992;128(1):39-42.
  • Antistreptococcal interventions for guttate and chronic plaque psoriasis (Review) 8 Copyright © 2016 The Cochrane Collaboration. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001976/epdf
  • Thorleifsdottir R.H. et al.; Improvement of Psoriasis after Tonsillectomy Is Associated with a Decrease in the Frequency of Circulating T Cells That Recognize Streptococcal Determinants and Homologous Skin Determinants; The Journal of Immunology; April 9, 2012, doi:10.4049/jimmunol.1102834
  • Moon Seub Shin et al; New Onset Guttate Psoriasis Following Pandemic H1N1 Influenza Vaccination; Ann Dermatol. 2013 November; 25(4): 489–492.

PSORIASIS and COMORBIDITIES and INFLAMMATORY BOWEL DISEASE

blog-6

WHAT IS COMORBIDITY?

 Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

INCREASED RISK

The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

CHART 1: Comorbidities Associated with Psoriasis

Inflammatory Bowel Disease (IBD) –

Crohn’s Disease

Ulcerative Colitis

Irritable Bowel Syndrome (IBS)

1, 2, 3

Gastro Intestinal (GI) disorders are present in 28% of patients with psoriasis. Common abnormalities in psoriasis patients include changes in the mucous membrane of the duodenum. Psoriasis may cause dermatogenic enteropathy and intestinal inflammation.

Irritable bowel syndrome (IBS) is one of the most common ‘functional’ gastrointestinal disorders accounting for 3% of all primary care consultations, with a strong female predominance. The main features are recurrent abdominal pain and/or discomfort, whose clear relationship to changes in stool frequency or consistency and its relief by defecation implies that they originate in the colon. In addition to these gastrointestinal (GI) symptoms, patients commonly report non-GI symptoms of lassitude, headache, backache, dysmenorrhoea (painful periods/menstruation), and dyspareunia (painful intercourse). Symptoms characteristically wax and wane. IBS patients, in common with other sufferers with functional GI disorders, are more anxious than healthy controls, showing greater anxiety and depression. Many patients believe that stress induces their symptoms.10

Inflammatory Bowel Disease (IBD) are a group of inflammatory conditions in which the body’s own immune system attacks parts of the digestive system. The two major types of IBD are ulcerative colitis (UC) and Crohn’s disease (CD). UC is limited to the colon and/or rectum (normally continuous lesions in the rectum and colon), and affects only the inner lining (mucosal and submucosal layers) of the gut. In contrast, CD can affect any part of the gut from mouth to anus as non-continuous or skip lesions (a majority of cases start in the terminal ileum), and affect the whole thickness of the bowel wall.4

stomach_etc_diagram-en-wikkip

Within the IBD group is also Microscopic Colitis, an inflammation of the colon that can only be detected with a microscope. There are two types of microscopic colitis – collagenous colitis and lymphocytic colitis. Under a microscope an increase in the number of lymphocytes, a type of white blood cell, can be seen in the epithelium—the layer of cells that lines the colon.15

The two types of colitis affect the colon tissue in slightly different ways:

  • Lymphocytic colitis – The number of lymphocytes is higher, whilst the tissues and lining of the colon are of normal thickness.
  • Collagenous colitis – The layer of collagen, a threadlike protein, underneath the epithelium builds up and becomes thicker than normal.

 The most common symptom of microscopic colitis is chronic, foul smelling, watery, non-bloody diarrhoea. Episodes of diarrhoea may last for weeks, months, or if chronic, even years, however, there may be intermittent periods without diarrhoea. During these periods the patient may even experience bouts of constipation.

Other signs and symptoms of microscopic colitis include15:-

  • A strong urgency to have a bowel movement.
  • Faecal incontinence – accidental passing of stool or fluid from the rectum – especially at night.
  • Pain, cramps, or bloating in the abdomen – that is usually mild but can be incapacitating.
  • Weight loss/gain
  • Nausea – usually without vomiting.
  • Dehydration – as a result from not drinking enough liquids to replace fluids lost through diarrhoea.
IBD SYMPTOMSIBS SYMPTOMS
Frequent and/or Urgent Bowel Movements

Diaorrhea

Bloody Stools

Abdominal Pain & Cramping

Fatigue

Weight Loss

Lack of Appetite

Joint, Skin or Eye Problems

Abdominal Pain & Cramping

Diaorrhea

Bloating

Gas

Mucus in Stools

 

As far back as 1968 studies reported a prevalence of 2-3% of psoriasis in first-degree relatives of patients with CD compared to 0–3% of controls. Later studies found psoriasis in 7–11% of the IBD population compared to 1–2% of general population. In one study, psoriasis was found to be more prevalent in CD (11.2%) than UC (5.7%). 5

In one study5 the Researchers studied the presence and characteristics of psoriasis were recorded and further classified as follows: sebopsoriasis, scalp psoriasis, plaque type psoriasis [trunk, arms], palmo-plantar psoriasis, nail psoriasis, inverse psoriasis, psoriatic arthritis, guttate psoriasis, and pustular psoriasis. Psoriasis that developed after anti-TNF? treatments was also reported. Severity of psoriasis was defined as mild, moderate or severe [not applied to psoriatic arthritis]. The study involved some 251 IBD patients, there were 158 patients with CD [63%] and 93 with UC [37%]. These 251 IBD patients were referred to the dermatologist and psoriasis was detected in 62 [25%], including 36 [58%] with CD and 26 [42%] with UC. The non-IBD group included 62 patients with psoriasis. Mild psoriasis was more frequent in IBD vs non-IBD, whereas moderate and severe psoriasis were more frequent in non-IBD vs IBD. Plaque-type psoriasis was the most common phenotype in both IBD and non-IBD. The frequency of plaque-type, nail psoriasis and psoriatic arthritis was lower in IBD vs non-IBD.

Other researchers analyzed the health records of 174,646 participants from the Nurses’ Health Study (NHS) and NHS II in an effort to also determine whether IBD was associated with specific psoriasis phenotypes. In this study they found 4,400 cases of psoriasis and of these 423 participants had developed CD or UC with a prevalence of psoriasis that was four to six times greater in IBD patients than the estimated prevalence in the general public.6

Several neutralizing anti-TNF agents, such as etanercept and infliximab, have been successfully used to treat autoimmune diseases, including inflammatory bowel disease. However, paradoxically, Infliximab and adalimumab-induced psoriasis in Crohn’s disease has been identified as a side effect of TNF-alpha inhibitor therapy. Researchers reviewed 142 case articles of new-onset psoriasis with infliximab, adalimumab, and etanercept therapy and of these confirmed eighty-one cases of infliximab induced psoriasis.7 In another study the researchers found that the vast majority of the cases (76%) developed psoriasis while on infliximab, and the rest (24%) after switching to adalimumab or certolizumab, indicating that this phenomenon is not drug specific, but rather a pharmacological group effect 12

 In another systematic literature review Researcher reviewed 222 cases. Of the 222 patients, 78.38% were diagnosed with Crohn’s disease, and 48.20% were female. The mean patient age was 26.50 years, and 70.72% of patients had no prior history of psoriasis. Infliximab was the anti-TNF-? therapy that caused the cutaneous reaction in most patients (69.37%). Clinical presentation varied; psoriasis-form lesions were the most common form of psoriasis (55.86%), followed by typical plaque type lesions (20.72%), and pustular-type lesions (3.60%). Six patients (2.70%) concomitantly presented with alopecia, one patient (0.45%) presented with palmoplantar pustulosis, and another patient (0.45%) presented with palmoplantar pustulosis and psoriatic arthritis.9

 Celiac disease is defined as a disease of the small intestine characterized by mucosal inflammation, villous atrophy, and crypt hyperplasia upon exposure to dietary gluten. Several studies have found that psoriasis patients are at an increased risk for celiac disease. A retrospective cohort study compared 25,341 psoriasis patients to over 125,000 matched controls in the U.S. The comparison data showed an odds ratio of 2.2 for the association of psoriasis with celiac disease. They also examined whether patients with celiac disease also have increased risk of psoriasis. A cohort of 28,958 biopsy-confirmed celiac disease patients from Sweden was evaluated for risk of future psoriasis compared to 143,910 age and sex-matched controls. The authors found a positive correlation between celiac disease antibody positivity and an increase in the severity of psoriasis or psoriatic arthritis. Interestingly, in the psoriasis patients, elevated celiac disease antibodies did not necessarily correspond to a biopsy-confirmed diagnosis of celiac disease, suggesting that psoriasis may be associated with gluten “sensitivity” (marked by antibody positivity) but not necessarily fully developed Celiac disease.10

In summary both Psoriasis and IBD and IBS are related inflammatory diseases. The skin and bowel represent both barrier and connection between the inner and the outer sides of the body. On average approximately 25% of patients who experience some form of bowel complaint will be diagnosed with psoriasis. It is also interesting to note that smoking in both IBD/IBS and psoriasis is considered an exacerbating trigger.

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Huang B.L. et al.; Skin manifestations of inflammatory bowel disease; Frontiers in Physiology; www.frontiersin.org February 2012 | Volume 3 | Article 13 | 1
  • Skroza et al.; Correlations between Psoriasis and Inflammatory Bowel Diseases; Hindawi Publishing Corporation BioMed Research International Volume 2013, Article ID 983902, 8 pages ; http://dx.doi.org/10.1155/2013/983902
  • Lolli E. et al.; Psoriasis Phenotype in Inflammatory Bowel Disease: A Case-Control Prospective Study; Journal of Crohn’s and Colitis, 2015, 699–707 doi:10.1093/ecco-jcc/jjv068 Advanced Access publication April 23, 2015
  • Li W.Q. et al.; Psoriasis, psoriatic arthritis and increased risk of incident Crohn’s disease in US women; Ann Rheum Dis. 2013 July ; 72(7): 1200–1205. doi:10.1136/annrheumdis-2012-202143
  • Famenini S. and Wu J.J.; Infliximab-Induced Psoriasis in Treatment of Crohn’s Disease-Associated Ankylosing Spondylitis: Case Report and Review of 142 Cases; J Drugs Dermatol.2013;12(8):939-943.
  • Denadai R .et al.; REVIEW ARTICLE Induction or exacerbation of psoriatic lesions during anti-TNF-? therapy for inflammatory bowel disease: A systematic literature review based on 222 cases; Journal of Crohn’s and Colitis (2013) 7, 517–524
  • Bhatia B.K. et al.; Diet and Psoriasis: Part 2. Celiac Disease and Role of a Gluten Free Diet; J Am Acad Dermatol. 2014 August ; 71(2): 350–358. doi:10.1016/j.jaad.2014.03.017.
  • Spiller R.C.; Irritable bowel syndrome; Published Online March 14, 2005; British Medical Bulletin 2004; 72: 15–29
  • Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006 Apr. 130(5):1480-91.
  • Bercik P. et al.; Is irritable bowel syndrome a low-grade inflammatory bowel disease?; Gastroenterol Clin North Am.2005 Jun;34(2):235-45, vi-vii.
  • Gionata Fiorino , Paolo D. Omodei; Psoriasis and Inflammatory Bowel Disease: Two Sides of the Same Coin?; Journal of Crohn’s and Colitis, 2015, 1–2
  • Microscopic colitis. Mayo Clinic website.mayoclinic.org/diseases-conditions/microscopic-colitis/home/ovc-20192308

TYPES OF PSORIASIS – PLAQUE PSORIASIS

blog-24

Plaque psoriasis or Psoriasis vulgaris (common type) – affects between 58% and 97% of all psoriasis cases. The difference in prevalence can be explained by race and geographical placement.1

It is characterized by sharply demarcated erythematous (red), silvery (whitish/yellowish), scaling plaques which most commonly occur on the elbows, knees, scalp, chest, back, and groin regions. The lesions are well-defined round or oval plaques that differ in size and in chronic plaque psoriasis often coalesce to form very large lesions covering large areas of the body.  Other involved areas include the ears, glans penis, perianal region, and sites of repeated trauma.

The lesions vary in size from 0.5 cm in diameter to large confluent areas on the trunk and limbs. There is a sharp line of demarcation between a plaque and clinically normal, uninvolved skin. Longitudinal studies of individual plaques have demonstrated that plaques are dynamic with an active and expanding edge, sometimes to the extent that the advancing edge may become annular leaving clinically normal skin in the centre of the original plaque.2,3

Plaque psoriasis can present in several different ways.

plaque-psoriasis

Figure 1. Plaque Psoriasis – colour varies from pinkish red to deep red, shiny with minimal silvery scale. Multiple lesions often coalesce forming larger plaques. This patient would be classified has having sever psoriasis

rupioid-sub-type

Figure 2. Plaque Psoriasis –  Rupioid subtype  Deep violaceous annular (round) lesions with distinctive, thickened, silvery scale. Multiple small lesions can be seen to be coalescing.

The term rupioid relates to distinct morphological subtype of plaque psoriasis. Rupioid plaques are small (2–5 cm in diameter) and highly hyperkeratotic, resembling limpet shells (see Figure 2).

A white blanching ring, known as Woronoff’s ring, may be observed in the skin surrounding a psoriatic plaque.

Other morphological subtypes of plaque psoriasis:-

  • Psoriasis gyrate — Figure 3 – in which curved linear patterns predominate annular psoriasis (psoriasis annularis – see figure 7 & 8) )—in which ring-like lesions develop secondary to central clearing

gyrate-sub-type Figure 3

  • Psoriasis follicularis — Figure 4 – in which minute scaly papules are present at the openings of pilosebaceous (hair) follicles.

Psoriasis - Folicularis Figure 4

  • Ostraceous psoriasis (see Figures 5 & 6 below) refers to hyperkeratotic plaques –  extremely thick scaled plaques often resembling an oyster shell.

ostraceous-fig-6 Figure 5                ostraceous-fig-5 Figure 6

Plaque psoriasis (see Figures 7 & 8 below) with a discoid (circular or oval) appearance is called psoriasis annularis or annular psoriasis.

psoriasis-annularis-fig-8 Figure 7                  Psoriasis - Annularis Figure 8 

Scale is typically present in plaque psoriasis, is characteristically silvery white, but may appear a yellowish colour and can vary in thickness.

Removal of scale may reveal tiny bleeding points (Auspitz sign – See Figure 9). The amount of scaling varies among patients and even at different sites on a given patient. In acute inflammatory or exanthematic psoriasis, scaling can be minimal and erythema may be the predominant clinical sign.4

OLYMPUS DIGITAL CAMERA
Figure 9. Thickened, red lesions with fine silvery scale. Multiple lesions have coalesced to form a large plaque. Note the excoriations marks where the patient has scratched the surface of the plaque to reveal pinpoint capillary bleeding, known as Auspitz sign
  • Lichenified psoriasis (Figure 10 and 11) – thickened psoriasis caused by chronic scratching (eczematized)

lichenified-2 Figure 10        lichenified Figure 11

Elephantine psoriasis (Figure 12 and 13) – large persistent, leathery plaques 

Psoriasis - Elephantine 1  Figure 12                Psoriasis - Elephantine Figure 13

Presentation examples of Plaque Psoriasis

Plaque Psoriasis 11 plaque-psoriasis-10  Plaque Psoriasis 9

plaque-psoriasis-8 plaque-psoriasis-7 plaque-psoriasis-6 plaque-psoriasis-5

Plaque Psoriasis 4 plaque-psoriasis-3  plaque-psoriasis-2 plaque-psoriasis-1

Read also “Psoriasis – Severity and Types”