“Some of our patients have never been to the beach. Not because they can’t go, but because they are too ashamed to go. They just want people to stop staring at them. This skin disease has a terrible impact on people’s quality of life. And the sad thing is that it can be very successfully treated if it is properly diagnosed – but many people either don’t seek treatment or, if they do, don’t always get an appropriate treatment.” Sr Judy Wallace is in charge of the dermatology ward at Groote Schuur hospital in Cape Town and is Chairperson of the South African Psoriasis Association. She expresses frustration about the general lack of awareness and understanding of psoriasis. “There is a lot of stigma attached to psoriasis”, she continues. “There is a misconception that it is contagious, which is completely untrue! And it has nothing to do with bad hygiene! Nevertheless, this can lead to people with psoriasis isolating themselves, and even having difficulty finding or keeping employment.”
The exact number of people with psoriasis is unknown, but it is estimated to affect up to about 3% of the world’s population – approximately 1 to 2 million people in South Africa.1 All ages may be affected, but it most commonly begins in the teenage and early adult years, before the age of 40.2,3 2. p1a; 3p25a . Thereafter, it tends to remain throughout life, although there may be periods of improvement, or even remission, followed by recurrences.2 p1a There is a strong genetic link to psoriasis. It occurs more commonly in people whose parents or siblings are affected. Almost three quarters of children with psoriasis have other members in their family with the condition, and the risk is doubled if a sibling and one parent have psoriasis.4 p1899a, b
Causes and symptoms
It is not known what causes psoriasis. However, studies show that immune cells in the skin behave abnormally, causing skin cells, blood vessels and nerves to grow faster than usual.4 p1906a,b Most commonly, in around 90% of people with psoriasis, this results in clearly demarcated patches or ‘plaques’ of thick, red skin, covered with white or silver scales (called psoriasis vulgaris). These normally occur on both sides of the body over the back of the elbows, front of the knees, on the lower back and around the umbilicus.3 p26a Approximately half of people with psoriasis also have involvement of the scalp or nails.3,4 3p26e; 4 p1900b The skin lesions can be very uncomfortable, causing itching, burning, bleeding and pain from irritated skin.5 p106a In addition to this, messy flaking and the unsightly cosmetic appearance of the skin and nails can be a source of acute embarrassment, self-consciousness and frustration.6 p664a
Other less common variants of the condition include inverse psoriasis, where the lesions occur on the joint creases and skin folds and tend not to scale; guttate psoriasis, with widely distributed small red, scaly, ‘tear drop’ skin lesions; and generalised pustular psoriasis in which the person is very unwell with rapidly progressing tender, pustules and widespread inflammation.3,4 3. p26 b; 4. p1900a
A flare-up or worsening of the skin plaques may be triggered by various environmental and personal factors, including change in climate, exposure to chemicals or detergents, heavy drinking and stress. Plaques of psoriasis vulgaris may be triggered by physical trauma or skin damage.2,4 2. p19a; 4.p1902a,b“Tattoos are notorious for triggering psoriasis”, says Dr Ayesha Moolla, a dermatologist in private practice in Gatesville in the Western Cape. “That’s because of the skin damage caused by the needle while it is being applied. We call this the Koebner phenomenon, where psoriasis develops at the site of an injury.”
Related health problems
Up to 1 in 4 people with psoriasis develop an associated arthritis that is characterised by joint pain, early morning stiffness and painful inflammation of the fingers or toes. This ‘psoriatic arthritis’ is progressive and, if left untreated, ultimately results in deformity.3 p26d People with psoriasis are also at increased risk of a number of other health problems, including diabetes, high blood pressure, high cholesterol, obesity, heart attack, inflammatory bowel disease, and certain types of cancer.5 p106b Depression and anxiety are also common and patients express a range of emotional reactions, including shame, embarrassment, and anger and helplessness.2 p10a “The mental health issues that affect people with psoriasis are grossly underestimated”, says Sr Wallace. “It sets up a vicious cycle, where the anxiety and psychological distress precipitates flare-ups and worsening psoriasis.” So the effects of psoriasis are far-reaching, affecting almost every aspect of the patient’s quality of life, including physical activities, psychological, social, sexual and occupational well-being.6 p663a
An early diagnosis is essential. However, there is a growing trend, says Dr Moolla, where people with skin diseases are self-diagnosing using the internet. “This is dangerous, because it means that frequently they get neither the correct diagnosis, nor the correct treatment. An untrained person can easily confuse psoriasis with other common skin conditions, and especially with eczema, which requires different types of treatment. You need to be properly assessed by a qualified healthcare worker.” Although there is no cure for psoriasis, symptoms can be controlled with treatment. Apart from managing the skin and improving psychological well-being, early diagnosis helps to identify people at risk of associated conditions and arthritis, where early recognition can reduce the chance of worsening health problems, joint damage and disability. 2, 3 2. p4a; 3.p27a
Treatment will be individualised, advises Dr Moolla, and depends on the severity, site and type of psoriasis, and on the patient. “Sometimes a number of treatments might need to be tried before we find the one that is the most effective.”
For mild to moderate psoriasis, especially where it affects relatively small areas of the skin, topical creams and ointments are sufficient to control the disease.3 p26f Where topical treatments fail or the lesions are too widely distributed for topical application, alternative options include ultraviolet therapy and oral or injectable therapies that help to reduce the abnormal activity of the immune system.3 p27g, h; p29g
“Topical treatments are extremely effective in many patients, and spare them from the side effects that can occur with oral medications”, says Sr Wallace. They include corticosteroids, vitamin D-based treatments, coal tar preparations and preparations to soften the skin or reduce abnormal growth of cells.2, 3 2.p14a; 3. p26f
An advance in topical treatment for psoriasis has been the development of a combination product containing betamethasone dipropionate and calcipotriol. On their own, both of these medications are effective, but, because they work against psoriasis in different ways, combining them together produces an additive effect. This combination has been shown in clinical studies to be rapidly and consistently effective and with fewer side effects than calcipotriol alone, helping to improve quality of life for patients with psoriasis. 6, 7 6. p663b; 7.p39a, p43a, p43b A combination solution is also available for scalp psoriasis. In one study, over two thirds of patients with scalp psoriasis were disease-free after 8 weeks of application of the two-component solution in comparison to less than half of those with calcipotriol solution alone.8 p170a
In comparison to some other treatments for psoriasis, both the combination skin preparation and scalp preparation are applied only once daily.
As psoriasis is a chronic disease, it requires lifelong treatment. Furthermore, it is important to keep the skin well moisturised and yourself well hydrated. Treatments should be used regularly, as prescribed to help prevent flare-ups. “Avoidance of too much sun exposure and sun burn, and excessive drinking and smoking can also help to control the disease,” advises Dr Moolla.
Both Dr Moolla and Sr Wallace recommend that people with psoriasis should join a psoriasis support group through organisations such as the SA Psoriasis Association (www.psoriasis.org.za).
“Joining a community that understands and shares experiences with people in the same boat, is one of the best ways of managing the disease. Likewise, the World Psoriasis Day website (www.worldpsoriasisday.com) is a valuable source of information, globally raising significant awareness of the disease,” concludes Dr Moolla.
|Comparison between atopic eczema and psoriasis|
(atopic eczema; dermatitis)
|Age group||Most common in childhood
(up to 1 in 5 children; 2%-10% of adults).9 p1a
|Most common in adults
(up to 3% of the population)1,2 2. p1a
|Peak age||Under 2 years, becomes less common with increasing age.9 p1b||May occur at any age, but usually begins in teens or before the age of 40.2,3 2. p1a 3. p25a|
|Course||Usually resolves during childhood, but may persist into adult life, or recur in teenage or early adult years.9 p1c||May be improvements followed by relapses, but tends to persist throughout life.2 p1a|
|Cause||Skin may be susceptible to allergy.9,10 9.p2b; 10.p1046a||The immune system is dysfunctional.4 p1904a|
|Genetic cause||Yes, it may run in families.10 p1046b||Yes, runs in families.4 p1899a|
|Environmental triggers||Yes, it may be an allergy to irritants, such as wool, chemicals, tobacco smoke, traffic exhaust; certain foods; or a bacterial skin infection.10
||Yes, worsening may be triggered by change in climate, injury to the skin, chemicals, detergents, or stress.2,4 2. p19a; 4. p1902a,b|
|Itching||Yes5 p105a||May be itching, burning or pain.5 p106a|
|Skin appearance||Dry skin, redness, blistering,
oozing, cracking, scaling, skin thickening and sometimes colour change (depends on severity and not all occur together).9 p2a, p5a
|Sharply demarcated inflamed plaques covered by silvery white scales.4 p1900a|
|Common sites||Skin creases: front of elbows, behind knees, fronts of ankles, around neck, around eyes, cheeks, forehead.9 p5b||Elbows, front of knees, scalp, umbilicus, lower back.4 p1900a|
|Associated conditions||Other allergies; e.g., asthma, allergic rhinitis (hay fever), eye allergies, allergy to food.10 p1046a; 1049b||Arthritis; increased risk for heart attack, diabetes, inflammatory bowel disease, depression.2 p9a,b|
- Profile of Psoriasis. World Psoriasis Day [online] 2014 [cited 16 Oct 2014]. Available from URL: http://www.worldpsoriasisday.com/web/page.aspx?refid=114.
2.Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and
psoriatic arthritis in adults. Edinburgh: SIGN; 2010. (SIGN publication no. 121). [cited 12 Oct 2010].
Available from URL: http://www.sign.ac.uk. Accessed 9 October 2014.
- Laws PM, Young HS. Update of the management of chronic psoriasis: new approaches and emerging treatment options. Clinical Cosmetic and Investigational Dermatology2010; 3: 25-37.
- Schön MP, Boehncke WH. Psoriasis. N Engl J Med2005; 352: 1899-1912.
- Ahmed A, Leon A, Butler DC, Reichenberg J. Quality-of-life effects of common dermatological diseases. Semin CutanMedSurg 2013; 32: 101-109.
- van der Kerkhof PCM. The impact of a two-compound product containing calcipotriol and betamethasone dipropionate (Daivobet®⁄ Dovobet®) on the quality of life in patients with psoriasis vulgaris: a randomized controlled trial. Br J Dermatol 2004; 151: 663-668.
- Kragballe K, van der Kerkhof PCM. Consistency of data in six phase III clinical studies of a two compound product containing calcipotriol and betamethasone dipropionate ointment for the treatment of psoriasis. J Eur Acad Dermatol Venereol2006; 20: 39-44.
- Van de Kerkhof PCM, Hoffman V, Anstey A, et al. A new scalp formulation of calcipotriol plus betamethasone dipropionate compared with each of its active ingredients in the same vehicle for the treatment of scalp psoriasis: a randomized, double-blind, controlled trial. Br J Dermatol2009; 160: 170-176.
- Scottish Intercollegiate Guidelines Network (SIGN). Management of atopic eczema in primary care. Edinburgh: SIGN; 2011. (SIGN publication no. 125). [March 2011]. Available from URL: http://www. sign.ac.uk. Accessed 9 October 2014.
- Ring J, Alomar A, Bieber T, et al. Guidelines for treatment of atopic eczema (atopic dermatitis) Part I. J Eur Acad Dermatol Venereol2012; 26: 1045-1060.