- Psoriasis in summer
- Risk factors
- Comorbid conditions associated with psoriasis
- Quality of life
- Preventive measures
Psoriasis is a skin condition underpinned by dysfunction of the immune system. It occurs in phases of relapse, remission (no symptoms) and exacerbation (severe symptoms). The primary symptom is papulosquamous skin rash, which is a red, scaly rash. Elbows, knees, scalp and trunk are the most commonly affected body parts; however, the disease can affect any body part. In mild cases the rash covers < 2% of the person’s body surface area. Disease is typically considered severe if it affects more than 10% of skin surface area. Up to 20% of people who have psoriasis have extensive skin rash. Joints are often also affected. The skin rash and other symptoms (e.g. those affecting the joints) which psoriasis causes are uncomfortable and may cause itching and burning sensations They also cause embarrassment which can have a serious impact on a person’s wellbeing.
For more information about psoriasis including types, treatments, videos and more, see Psoriasis.
The skin symptoms of psoriasis are more likely to improve spontaneously (without treatment) in summer, compared to other times of the year. However, the psychological effects of the condition may be worse during summer due to the need to expose more skin in warm conditions. Because skin rash is a highly visible symptom, it is difficult to hide from other people during summer. However, exposing the skin can be embarrassing and lead to stigma and discrimination.
People with psoriasis may be too embarrassed to participate in summer recreation activities which require the removal of clothing, such as swimming and other sports. In one study, a large proportion of people with psoriasis reported avoiding swimming and/or other sporting activities as a result of their condition. 64% reported that they avoided buying summer clothes such as short sleeved shirts, summer dresses and/or shorts. Wearing seasonally inappropriate clothing (e.g. long sleeves in summer) in an attempt to hide psoriatic skin rash is one measure people resort to in order to hide their condition. However, this strategy is also likely to draw unwanted attention.
Psoriasis is a common condition. Studies from different developed countries have reported that it affects between 1 and 4% of the total population. InAustraliaprevalence is estimated to be between 0.3–2.5% of the population. It is the reason for some 0.3–0.6% of doctor visits overall and 2.6% of all skin-related doctor visits.
Prevalence is low (0.55%) in patients < 10 years of age and increases with increasing age. Men and women are just as likely to have psoriasis; however, young females (< 20 years) have a higher risk of the disorder compared to young males. While it is uncommon to develop psoriasis in childhood or adolescence, those individuals who do tend to have more severe disease. They usually also have family members affected by psoriasis. The psychological effects of the disorder may be greater in patients who develop the condition later in life.
Psoriasis has a strong genetic element (it runs in families). The risk of inheriting the condition is greatest in children with both parents and a sibling affected, and children with one or both parents (but no sibling) affected are also at increased risk. Age of onset is also influenced genetically, so people whose parents developed the condition early in life are also likely to develop psoriasis early in life. Studies have identified several genes which may affect the risk of a person developing psoriasis.
Caucasians are more likely to experience psoriasis compared to other races. Individuals of Asian ethnicity have a lower risk than Caucasians and the condition is very rare in those of African ethnicity. The disease is also very rare in individuals of Native American descent.
Emotional stress is associated with acute attacks of psoriasis. In one study 60% of people reported a stressful life event in the month prior to acute symptoms of psoriasis.
There is clear evidence that injury is a risk factor for the development of psoriasis.
Psoriasis is less common in regions characterised by warm sunny weather conditions.
Biological factors (factors relating to the person’s body), including infection and medication use, also play a role in the development of psoriasis.
Individuals infected with HIV and those with chronic streptococcal infection have an increased risk of developing psoriasis. Those who already have psoriasis when they are infected with HIV or streptococci are likely to experience worsening psoriasis.
Using some medications can trigger the symptoms of psoriasis to worsen. Medicines known to have this effect include:
- Corticosteroids (if a person stops taking them too quickly); and
- Beta blockers.
Smoking is an important modifiable risk behaviour for psoriasis. In one study smokers were 1.3 times more likely to develop psoriasis compared to non-smokers.
Alcohol consumption has affects on most body systems and organs, including the skin. Psoriasis has also been associated with alcohol consumption in some studies, although others have found no association.
Psoriasis is commonly comorbid with other diseases (the person has psoriasis and these conditions are the same time). These include:
- Cardiovascular disease;
- Psoriatic arthritis a form of arthritis which affects 25% of psoriasis patients;
- Metabolic syndrome and diabetes mellitus;
- Cancer, particularly skin cancer and lymphoma, although it is unclear if psoriasis or its treatment underlies the increased risk of cancer;
- Psychological conditions including depression and mood disorders;
- Other conditions underpinned by immune dysfunction including colitis and Crohn’s disease.
Epidemiological evidence shows that the risk of some conditions (diabetes and obesity) increases with increasing psoriasis severity.
Psoriasis skin rash is typically itchy and changes the appearance of skin causing redness and scaling. Psoriatic rash is physically uncomfortable, but also associated with a range of psychological problems. It is often misinterpreted by others to be a symptom of a contagious skin disorder or other condition. For example 57% of people with psoriasis report others believe their condition to be contagious, and 9% that their psoriasis rash was mistakenly interpreted to be a symptom of acquired immune deficiency syndrome (AIDS). Psychosocial problems are particularly likely and more severe in people with affected skin on the face, hands or other commonly exposed body areas. They may also be worse in summer, when warm conditions lead to many people exposing greater amounts of skin. People with psoriasis may resort to wearing clothing which is inappropriate for hot weather to hide their rash.
The quality of life impact of psoriasis is often significant and people aged < 55 years are most likely to experience negative quality of life effects. The majority of people affected by the condition (79%) report that the condition negatively affects their quality of life. It may affect social, intimate and work relationships, daily living and self perception. Women are more greatly affected in terms of quality of life compared to men.
Psoriasis is reported to affect people’s relationships with family members, friends and intimate partners. Those affected by the condition report feeling physically and sexually unattractive. Sexual activity is also often affected, particularly amongst those ≤ 54 years, amongst whom 27% report the condition negatively affects their sex life. People with psoriasis may also have difficulty interacting with family or friends and difficulty maintaining friendships. Some 7% of those affected report that they have been excluded from public facilities such as swimming pools, gymnasiums and hair dressing salons and 40% report difficulty getting equal service or treatment at these facilities. This may also affect their ability to maintain social relationships. In one study, 11% of people with psoriasis reported not wanting to have children for fear that they would inherit the condition.
Psoriasis is associated with difficulties finding employment and 6% of workers with psoriasis report experiencing discrimination at work. Those who had a job reported that the condition negatively affected their ability to interact with colleagues and was the cause of an average of 2.3 days off work each year. Absenteeism from work was reported to be the source of some 40% of the total costs associated with the disease (US $11.25 billion annually in theUnited States) in one study. In another, 35% of people with psoriasis reported the condition affected their career and 20% that it impaired their functioning at work. Work-related stress appears to be greater in men with psoriasis compared to women.
Daily living activities such as those requiring the use of hands and walking are impacted by psoriasis in a significant minority of those affected (19% and 14% respectively). Of those who also have psoriatic arthritis, 66% experienced difficulty using their hands and 63% experienced difficulty walking. Sleep is also impacted in many people, with > 20% reporting sleep difficulties associated with the condition. Sitting or standing for long periods of time or performing duties at work is also difficult for some people affected by psoriasis.
Patients with severe psoriasis report their daily living is affected 10% of the time. Treating psoriasis may be time consuming and on average those using topical treatments like skin creams report spending 26 minutes per day applying the treatments. The impact on physical and mental functioning associated with the condition is comparable to that associated with arthritis, depression, cancer and heart disease.
Psoriasis creates economic hardship for those affected by limiting their ability to work and their income earning capacity, and also due to the cost associated with managing the condition. In a study of patients in theUnited Kingdom, 31% reported the condition caused them financial distress. Treatment may be expensive, particularly new biological therapies.
Psoriasis often has a severe psychological impact and 10% of affected individuals between 18–34 years of age report that they have contemplated suicide. The vast majority report less serious psychological complaints including concern for the future, embarrassment, negative self-image and depressed feelings. Young people (18–34 years old) experience psychological complaints most often, with 81% reporting feeling embarrassed when people saw their skin rash and 75% reporting they felt ugly. In this age group concerns about their condition getting worse in the future were reported by the vast majority (88%). Psychological ill health is more likely if face and hands are affected or the rash is extensive. People who are dependent on alcohol also experience more severe psychological consequences of psoriasis.
Psoriasis is a chronic disease for which there is currently no cure. Those affected will be affected for life. While nothing can cure the immune dysfunction which causes psoriatic skin rash, lifestyle measures reduce the severity of the symptoms for many people.
Avoiding things which trigger psoriasis skin symptoms is an important preventive measure. Common triggers include:
- Some drugs, particularly lithium, beta-blockers, interferons and anti-malarials).
Increasing alcohol consumption is associated with increasing disease severity in men, and both men and women who consume alcohol have an increased risk of psoriasis. Therefore, reducing alcohol consumption is an important behaviour for preventing psoriatic skin rash.
Smokers are 1.3 times more likely to develop psoriasis compared to non-smokers. Quitting smoking is a key lifestyle measure for reducing risk of the disease. Quitting smoking (and reducing alcohol consumption) are both important parts of treatment, as use of either reduces the likelihood that treatment will be effective. Individuals who drink too much alcohol are less likely to take their psoriasis medicines correctly and thus are less likely to get the full benefit of their treatment.
Treatment options for people with psoriasis have developed considerably since 2007 and there is now a greater choice of effective therapies on offer. The best choice of treatment depends on the individual being treated and factors like:
- The extent, severity and site of their psoriatic lesions;
- Things which trigger psoriasis symptoms;
- The impact of the disease on quality of life and daily functioning;
- Comorbid disease; and
- factors which may affect treatment compliance.
Although severity of disease influences a person’s psychological response and the quality of life impact they experience, different people respond to psoriasis in different ways. Some people with mild psoriasis are seriously affected by psychological complaints, while others with severe psoriasis have few psychological complaints.
As many different factors influence the best choice of treatment, individuals with psoriasis must speak openly with their doctor about how the disease affects them physically and psychologically. They also need to discuss their treatment priorities with the doctor. While treatment aims to relieve the skin symptoms, people receiving treatment may also be concerned (and in some cases may be more concerned) about improving quality of life, or finding a treatment that is convenient.
It’s also important to speak to the doctor about the aims of treatment and to understand that treatment may alleviate the symptoms of psoriasis, but cannot cure the underlying immune dysfunction which causes the disease. Psoriasis is a life-long condition and is associated with significant morbidity (ill health). However, people with the condition may underestimate the severity of their condition and the impact psoriasis has on their health. For example, in one study 39% of people reported psoriasis affected > 10% of skin surface; however, only 17% classified their disease as severe.
Understanding the severity of the disease is important for ensuring the best treatment is chosen, particularly for those whose psoriasis fails to respond to topical treatments (those applied directly to the skin rash) like creams and gels. These people need to weigh up the risks and benefits of systemic treatments such as medicines and phototherapy, which can have significant side effects and in some cases require frequent doctor appointments. If the impact of psoriasis is underestimated, the benefits of treatment may also be underestimated in the risk benefit analysis.
Topical treatments such as creams and gels which are applied directly to the site of psoriatic skin rash are the most commonly used therapies. Topical treatments are typically safe and may be used alone (in cases of mild disease) or in combination with systemic or phototherapies (discussed below) in cases of moderate-severe disease. When deciding which topical treatment is best, it is important to consider the time and difficulty involved in applying the treatment. Preparations which can be applied easily with little mess are recommended, as when the treatment is easy to use, it is more likely to be used frequently and as recommended by the doctor.
Topical treatments are used by 87% of people with severe psoriasis. In cases of mild psoriasis (affecting < 5% of body surface area) they are highly effective. Topical therapies also play an important role in the management of moderate-severe disease because when people use creams and gels, they do not need to use as much medicine or other forms of systemic treatment which have greater side effects and/or are less convenient to use. When used alone, creams and gels are generally not enough to control severe psoriasis.owever the majority of people with severe disease report never having used more intensive photo and systemic therapies. This indicates that those with severe disease there is a greater role for topical treatments to be used in combination with more intensive therapies. Individuals who fail to control their skin rash, should consider and discuss with their doctor, using systemic therapies.
Phototherapy should be considered by all adults with extensive psoriatic skin rash which does not improve adequately with topical treatment. Two options are available. UVB therapy (which uses UVB rays) is most appropriate for patients with localised skin rash (restricted to a particular area of the body) while PUVA photochemotherapy is most appropriate for thick psoriatic rash.
Phototherapy is a highly effective form of treatment. 64% of people who had used phototherapy in oneUKstudy reported a good or excellent response. However, only a minority (23%) of people with severe psoriasis have used phototherapy. One thing which limits the use of phototherapy is the need for treatment to be administered in a specialised facility. For the individual being treated this means time, travel and inconvenience. However, in cases of severe disease the benefits of treatment might outweigh the time and inconvenience involved in using it.
Systemic treatments are medicines which affect the entire body, not only the site of psoriatic skin lesions. For example, medicines which are swallowed enter the blood stream and are distributed throughout the entire body. They are typically only used to treat psoriatic skin rash which affects > 5% of the body surface area and cannot be adequately controlled using topical or phototherapy. They include:
- Corticosteroids (cyclosporin);
- Folic acid antagonists (methotrexate); and
- Retinols (acitretin).
Methotrexate is considered the best choice and 70% of people with psoriasis who use it report a good or excellent response to the treatment. However, it is used by only a minority (27%) of people with severe disease.
Novel biologic agents for psoriasis treatment target the processes which underpin the development of psoriatic lesions. Psoriasis is underpinned by a dysfunctional immune response, so biological agents target cells in the immune system including cytokines and T cells. These cells play a role in regulating the immune system’s response, including the dysfunctional (overactive) immune responses which cause psoriatic rash to develop. Targeting these cells modifies (reduces) the immune system response and reduces psoriatic skin rash.
Because biological agents interfere with the immune system, it is important for people who use these treatments to undergo screening for infectious disease before they begin using them. Any severe infections, including tuberculosis and hepatitis B or hepatitis C should be treated before biological therapy commences.
Due to the high rate of side effects with conventional psoriasis treatment, many people with the condition consider using alternative therapies. In one survey almost half (43%) of the respondents reported trying over-the-counter medications or alternative therapies including herbal remedies, acupuncture and relaxation to treat psoriasis. 10% of the people were using some form of alternative therapy at the time of the survey. The majority (52%) reported no improvement in their condition with use of alternative therapy. There is little evidence to suggest that alternative therapies are effective in treating psoriasis. However, those who are interested in trying alternative therapies should discuss the available evidence with their doctor.
Dietary modifications may reduce the severity of psoriatic rash; however, evidence is limited. As the condition is underpinned by inflammation, an anti-inflammatory diet may be of benefit. Such a diet is based on the consumption of omega-3 fatty acids, whole grains, legumes, and fresh fruit and vegetables and avoidance of omega-6, saturated and trans fats and processed foods. It should also include the use of spices with anti-inflammatory properties such as ginger, cumin, basil and turmeric.
Identifying and avoiding food allergens which trigger psoriasis is another possible strategy. Many people with psoriasis are gluten intolerant and a gluten-free diet may be beneficial for this group. Obesity is a risk factor for the condition and maintaining a healthy weight is important.
Dietary supplements may also be beneficial for people with psoriasis. Oral (by mouth) or intravenous (injected into a vein) supplementation with fish oil is one supplement with possible benefits. Topical fish oil therapy is an option but most people find it unpleasant to use because of the odour of the oil. Folic acid supplementation is essential for people using the folic acid antagonist, methotrexate. Oral and topical vitamin D have also proven effective in treating psoriasis. Recent evidence for a dietary supplement based on proteins isolated from cows is promising; the therapy is safe and significantly reduced disease severity compared to no treatment in one study.
A range of non-pharmaceutical topical therapies have also been shown to improve psoriasis. Cream containing aloe vera extract reduced the extent of psoriatic lesions compared to no treatment in one study. Emollients (skin softeners), particularly those containing ceramides (fatty acids which hold water), regulate the water-holding capacity of the skin and have been show to reduce the scaliness of psoriasis.
Lifestyle measures which may assist in the treatment of psoriasis include:
- Bathing and sun bathing at theDead Seafor a period of 4 weeks;
- Increasing physical activity, particularly outdoor physical activity;
- Weight management for those with excessive body mass index (BMI) (who are overweight or obese);
- Quitting smoking;
- Reducing alcohol consumption; and
- Stress management.
Psychotherapy is essential for people who experience ongoing psychological difficulties as a result of their psoriasis. Medical treatment may not be appropriate as many medicines used for psychological conditions may worsen psoriasis. People who also have alcohol dependence disorder (are alcoholic) are less likely to respond to treatment and less likely to comply with their treatment plan (e.g. take their medicine as scheduled). These people may also need to access alcohol rehabilitation services.
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