Psoriasis is a common skin disease that
affects the life cycle of skin cells. Psoriasis causes cells to build up
rapidly on the surface of the skin, forming thick silvery scales and
itchy, dry, red patches that are sometimes painful.
Psoriasis is a persistent, long-lasting (chronic) disease. You may have
periods when your psoriasis symptoms improve or go into remission
alternating with times your psoriasis worsens.
For some people, psoriasis is just a nuisance. For others, it's
disabling, especially when associated with arthritis. No cure exists,
but psoriasis treatments may offer significant relief. Lifestyle
measures, such as using a nonprescription cortisone cream and exposing
your skin to small amounts of natural sunlight, can improve your
Psoriasis signs and symptoms can vary from person to person but may include one or more of the following:
* Red patches of skin covered with silvery scales
* Small scaling spots (commonly seen in children)
* Dry, cracked skin that may bleed
* Itching, burning or soreness
* Thickened, pitted or ridged nails
* Swollen and stiff joints
Psoriasis patches can range from a few spots of dandruff-like scaling to
major eruptions that cover large areas. Mild cases of psoriasis may be a
nuisance. But more severe cases can be painful, disfiguring and
Most types of psoriasis go through cycles, flaring for a few weeks or
months, then subsiding for a time or even going into complete remission.
In most cases, however, the disease eventually returns.
Several types of psoriasis exist. These include:
* Plaque psoriasis. The most common form, plaque psoriasis causes
dry, raised, red skin lesions (plaques) covered with silvery scales. The
plaques itch or may be painful and can occur anywhere on your body,
including your genitals and the soft tissue inside your mouth. You may
have just a few plaques or many, and in severe cases, the skin around
your joints may crack and bleed.
* Nail psoriasis. Psoriasis can affect fingernails and toenails,
causing pitting, abnormal nail growth and discoloration. Psoriatic nails
may become loose and separate from the nail bed (onycholysis). Severe
cases may cause the nail to crumble.
* Scalp psoriasis. Psoriasis on the scalp appears as red, itchy
areas with silvery-white scales. You may notice flakes of dead skin in
your hair or on your shoulders, especially after scratching your scalp.
* Guttate psoriasis. This primarily affects people younger than 30
and is usually triggered by a bacterial infection such as strep throat.
It's marked by small, water-drop-shaped sores on your trunk, arms, legs
and scalp. The sores are covered by a fine scale and aren't as thick as
typical plaques are. You may have a single outbreak that goes away on
its own, or you may have repeated episodes, especially if you have
ongoing respiratory infections.
* Inverse psoriasis. Mainly affecting the skin in the armpits,
groin, under the breasts and around the genitals, inverse psoriasis
causes smooth patches of red, inflamed skin. It's more common in
overweight people and is worsened by friction and sweating.
* Pustular psoriasis. This uncommon form of psoriasis can occur in
widespread patches (generalized pustular psoriasis) or in smaller areas
on your hands, feet or fingertips. It generally develops quickly, with
pus-filled blisters appearing just hours after your skin becomes red and
tender. The blisters dry within a day or two but may reappear every few
days or weeks. Generalized pustular psoriasis can also cause fever,
chills, severe itching and fatigue.
* Erythrodermic psoriasis. The least common type of psoriasis,
erythrodermic psoriasis can cover your entire body with a red, peeling
rash that can itch or burn intensely. It may be triggered by severe
sunburn, by corticosteroids and other medications, or by another type of
psoriasis that's poorly controlled.
* Psoriatic arthritis. In addition to inflamed, scaly skin,
psoriatic arthritis causes pitted, discolored nails and the swollen,
painful joints that are typical of arthritis. It can also lead to
inflammatory eye conditions such as conjunctivitis. Symptoms range from
mild to severe. Although the disease usually isn't as crippling as other
forms of arthritis, it can cause stiffness and progressive joint damage
that in the most serious cases may lead to permanent deformity.
When to see a doctor
If you suspect that you may have psoriasis, see your doctor for a
complete examination. Also, talk to your doctor if your psoriasis:
* Progresses beyond the nuisance stage, causing you discomfort and pain
* Makes performing routine tasks difficult
* Causes you concern about the appearance of your skin
Be sure to seek medical advice if your signs and symptoms worsen or they
don't improve with treatment. You may need a different medication or a
combination of treatments to manage the psoriasis.
The cause of psoriasis is related to the immune system, and more
specifically, a type of white blood cell called a T lymphocyte or T
cell. Normally, T cells travel throughout the body to detect and fight
off foreign substances, such as viruses or bacteria. If you have
psoriasis, however, the T cells attack healthy skin cells by mistake as
if to heal a wound or to fight an infection.
Overactive T cells trigger other immune responses including dilation of
blood vessels in the skin around the plaques and an increase in other
white blood cells that can enter the epidermis. These changes result in
an increased production of both healthy skin cells and more T cells and
other white blood cells. What results is an ongoing cycle in which new
skin cells move to the outermost layer of skin too quickly — in days
rather than weeks. Dead skin and white blood cells can't slough off
quickly enough and build up in thick, scaly patches on the skin's
surface. This usually doesn't stop unless treatment interrupts the
Just what causes T cells to malfunction in people with psoriasis isn't
entirely clear, although researchers think genetic and environmental
factors both play a role.
Psoriasis typically starts or worsens because of a trigger that you may
be able to identify and avoid. Factors that may trigger psoriasis
* Infections, such as strep throat or thrush
* Injury to the skin, such as a cut or scrape, bug bite, or a severe sunburn
* Cold weather
* Heavy alcohol consumption
* Certain medications — including lithium, which is prescribed for
bipolar disorder; high blood pressure medications such as beta blockers;
antimalarial drugs; and iodides
Anyone can develop psoriasis, but these factors can increase your risk of developing the disease:
* Family history. Perhaps the most significant risk factor for
psoriasis is having a family history of the disease. About one in three
people with psoriasis has a close relative who also has the condition.
* Other medical conditions. People with HIV are more likely to
develop psoriasis than people with healthy immune systems are. Children
and young adults with recurring infections, particularly strep throat,
also may be at increased risk.
* Stress. Because stress can impact your immune system, high stress levels may increase your risk of psoriasis.
* Obesity. Excess weight increases your risk of inverse psoriasis.
In addition, plaques associated with all types of psoriasis often
develop in skin creases and folds.
* Smoking. Smoking tobacco not only increases your risk of psoriasis
but also may increase the severity of the disease. Smoking may also
play a role in the initial development of the disease.
Depending on the type and location of the psoriasis and how widespread
the disease is, psoriasis can cause complications. These include:
* Thickened skin and bacterial skin infections caused by scratching in an attempt to relieve severe itching
* Fluid and electrolyte imbalance in the case of severe pustular psoriasis
* Low self-esteem
* Social isolation
In addition, psoriatic arthritis can be debilitating and painful, making
it difficult to go about your daily routine. Despite medications,
psoriatic arthritis can cause erosion in your joints.
Preparing for your appointment
You're likely to start by first seeing your family doctor or a general
practitioner. However, in some cases when you call to set up an
appointment, you may be referred directly to a specialist in skin
Because appointments can be brief, and because there's often a lot to
cover, it's a good idea to be well prepared for your appointment. Here's
some information to help you get ready for your appointment, and what
to expect from your doctor.
What you can do
* Write down any symptoms you're experiencing, including any that
may seem unrelated to the reason for which you scheduled the
* Make a list of all medications, including vitamins, herbs and
over-the-counter drugs that you're taking. Even better, take the
original bottles and a written list of the dosages and directions.
* Write down questions to ask your doctor. Don't be afraid to ask
questions or to speak up when you don't understand something your doctor
List your questions from most important to least important in case your
time with your doctor runs out. For psoriasis, some basic questions you
might ask your doctor include:
* What might be causing the signs and symptoms?
* Are tests needed to confirm the diagnosis?
* What is the best course of action?
* Is this condition temporary or chronic?
* Is there a generic alternative to the medicine you're prescribing?
* Can I wait to see if the condition goes away on its own?
* What are the alternatives to the primary approach that you're suggesting?
* What skin care routines do you recommend to improve my symptoms?
What to expect from your doctor
Your doctor is likely to ask you several questions. Being ready to
answer them may reserve time to go over any points you want to discuss
more. Your doctor may ask:
* When did you first begin experiencing symptoms?
* How often do you experience these symptoms?
* Have your symptoms been continuous, or occasional?
* What, if anything, seems to improve your symptoms?
* What, if anything, appears to worsen your symptoms?
Tests and diagnosis
Your doctor can usually diagnose psoriasis after talking to you about
your signs and symptoms and examining your skin. Sometimes, however,
your doctor may take a small sample of skin (biopsy) that's examined
under a microscope to determine the exact type of psoriasis and to rule
out other disorders. A skin biopsy is usually done in a doctor's office
using a local anesthetic.
Other disorders that can look like psoriasis include:
* Seborrheic dermatitis. This type of dermatitis is characterized by
greasy, scaly, itchy, red skin. It's often found on oily areas of the
body, such as the face, upper chest and back. Seborrheic dermatitis can
also appear on the scalp as stubborn, itchy dandruff.
* Lichen planus. This is an inflammatory skin condition that appears
as rows of itchy, flat-topped bumps (lesions) on the arms and legs.
* Ringworm of the body (tinea corporis). Ringworm is caused by a
fungal infection on the top layer of your skin. The infection often
causes a red, scaly ring or circle of rash.
* Pityriasis rosea. This common skin condition usually begins as one
large spot (herald patch) on your chest, abdomen or back, which then
spreads. The rash of pityriasis rosea often extends from the middle of
the body, and its shape resembles drooping pine-tree branches.
Treatments and drugs
Psoriasis treatments aim to:
* Interrupt the cycle that causes an increased production of skin cells, thereby reducing inflammation and plaque formation.
* Remove scale and smooth the skin, which is particularly true of topical treatments that you apply to your skin.
Psoriasis treatments can be divided into three main types: topical treatments, light therapy and oral medications.
Used alone, creams and ointments that you apply to your skin can
effectively treat mild to moderate psoriasis. When the disease is more
severe, creams are likely to be combined with oral medications or light
therapy. Topical psoriasis treatments include:
* Topical corticosteroids. These powerful anti-inflammatory drugs
are the most frequently prescribed medications for treating mild to
moderate psoriasis. They slow cell turnover by suppressing the immune
system, which reduces inflammation and relieves associated itching.
Topical corticosteroids range in strength, from mild to very strong.
Low-potency corticosteroid ointments are usually recommended for
sensitive areas, such as your face or skin folds, and for treating
widespread patches of damaged skin. Your doctor may prescribe stronger
corticosteroid ointment for small areas of your skin, for persistent
plaques on your hands or feet, or when other treatments have failed.
Medicated foams and scalp solutions are available to treat psoriasis
patches on the scalp. To minimize side effects and to increase
effectiveness, topical corticosteroids are generally used on active
outbreaks until they're under control.
* Vitamin D analogues. These synthetic forms of vitamin D slow down
the growth of skin cells. Calcipotriene (Dovonex) is a prescription
cream, ointment or solution containing a vitamin D analogue that may be
used alone to treat mild to moderate psoriasis or in combination with
other topical medications or phototherapy.
* Anthralin. This medication is believed to normalize DNA activity
in skin cells. Anthralin (Dritho-Scalp) can also remove scale, making
the skin smoother. However, anthralin stains virtually anything it
touches, including skin, clothing, countertops and bedding. For that
reason doctors often recommend short-contact treatment — allowing the
cream to stay on your skin for a brief time before washing it off.
Anthralin is sometimes used in combination with ultraviolet light.
* Topical retinoids. These are commonly used to treat acne and
sun-damaged skin, but tazarotene (Tazorac, Avage) was developed
specifically for the treatment of psoriasis. Like other vitamin A
derivatives, it normalizes DNA activity in skin cells and may decrease
inflammation. The most common side effect is skin irritation. It may
also increase sensitivity to sunlight, so sunscreen should be applied
while using the medication. Although the risk of birth defects is far
lower for topical retinoids than for oral retinoids, your doctor needs
to know if you're pregnant or intend to become pregnant if you're using
* Calcineurin inhibitors. Currently, calcineurin inhibitors
(tacrolimus and pimecrolimus) are only approved for the treatment of
atopic dermatitis, but studies have shown them to be effective at times
in the treatment of psoriasis as well. Calcineurin inhibitors are
thought to disrupt the activation of T cells, which in turn reduces
inflammation and plaque buildup. The most common side effect is skin
irritation. Calcineurin inhibitors are not recommended for long-term or
continuous use because of a potential increased risk of skin cancer and
lymphoma. Calcineurin inhibitors are only used with your doctor's input
and approval. They may be especially helpful in areas of thin skin, such
as around the eyes, where steroid creams or retinoids are too
irritating or may cause harmful effects.
* Salicylic acid. Available over-the-counter (nonprescription) and
by prescription, salicylic acid promotes sloughing of dead skin cells
and reduces scaling. Sometimes it's combined with other medications,
such as topical corticosteroids or coal tar, to increase its
effectiveness. Salicylic acid is available in medicated shampoos and
scalp solutions to treat scalp psoriasis.
* Coal tar. A thick, black byproduct of the manufacture of petroleum
products and coal, coal tar is probably the oldest treatment for
psoriasis. It reduces scaling, itching and inflammation. Exactly how it
works isn't known. Coal tar has few known side effects, but it's messy,
stains clothing and bedding, and has a strong odor. Coal tar is
available in over-the-counter shampoos, creams and oils.
* Moisturizers. By themselves, moisturizing creams won't heal
psoriasis, but they can reduce itching and scaling and can help combat
the dryness that results from other therapies. Moisturizers in an
ointment base are usually more effective than are lighter creams and
Light therapy (phototherapy)
As the name suggests, this psoriasis treatment uses natural or
artificial ultraviolet light. The simplest and easiest form of
phototherapy involves exposing your skin to controlled amounts of
natural sunlight. Other forms of light therapy include the use of
artificial ultraviolet A (UVA) or ultraviolet B (UVB) light either alone
or in combination with medications.
* Sunlight. Ultraviolet (UV) light is a wavelength of light in a
range too short for the human eye to see. When exposed to UV rays in
sunlight or artificial light, the activated T cells in the skin die.
This slows skin cell turnover and reduces scaling and inflammation.
Brief, daily exposures to small amounts of sunlight may improve
psoriasis, but intense sun exposure can worsen symptoms and cause skin
damage. Before beginning a sunlight regimen, ask your doctor about the
safest way to use natural sunlight for psoriasis treatment.
* UVB phototherapy. Controlled doses of UVB light from an artificial
light source may improve mild to moderate psoriasis symptoms. UVB
phototherapy, also called broadband UVB, can be used to treat single
patches, widespread psoriasis and psoriasis that resists topical
treatments. Short-term side effects may include redness, itching and dry
skin. Using a moisturizer may help decrease these side effects.
* Narrowband UVB therapy. A newer type of psoriasis treatment,
narrowband UVB therapy may be more effective than broadband UVB
treatment. It's usually administered two or three times a week until the
skin improves, then maintenance may require only weekly sessions.
Narrowband UVB therapy may cause more severe and longer lasting burns,
* Photochemotherapy, or psoralen plus ultraviolet A (PUVA).
Photochemotherapy involves taking a light-sensitizing medication
(psoralen) before exposure to UVA light. UVA light penetrates deeper
into the skin than does UVB light, and psoralen makes the skin more
responsive to UVA exposure. This more aggressive treatment consistently
improves skin and is often used for more severe cases of psoriasis. PUVA
involves two or three treatments a week for a prescribed number of
weeks. Short-term side effects include nausea, headache, burning and
itching. Long-term side effects include dry and wrinkled skin, freckles
and increased risk of skin cancer, including melanoma, the most serious
form of skin cancer.
* Excimer laser. This form of light therapy, used for mild to
moderate psoriasis, treats only the involved skin. A controlled beam of
UVB light of a specific wavelength is directed to the psoriasis plaques
to control scaling and inflammation. Healthy skin surrounding the
patches isn't harmed. Excimer laser therapy requires fewer sessions than
does traditional phototherapy because more powerful UVB light is used.
Side effects can include redness and blistering.
* Combination light therapy. Combining UV light with other
treatments such as retinoids frequently improves phototherapy's
effectiveness. Combination therapies are often used after other
phototherapy options are ineffective. Some doctors give UVB treatment in
conjunction with coal tar, called the Goeckerman treatment. The two
therapies together are more effective than either alone because coal tar
makes skin more receptive to UVB light. Another method, the Ingram
regimen, combines UVB therapy with a coal tar bath and an
anthralin-salicylic acid paste that's left on your skin for several
hours or overnight.
Oral or injected medications
If you have severe psoriasis or it's resistant to other types of
treatment, your doctor may prescribe oral or injected drugs. Because of
severe side effects, some of these medications are used for just brief
periods of time and may be alternated with other forms of treatment.
* Retinoids. Related to vitamin A, this group of drugs may reduce
the production of skin cells if you have severe psoriasis that doesn't
respond to other therapies. Signs and symptoms usually return once
therapy is discontinued, however. Side effects may include dryness of
the skin and mucous membranes, itching and hair loss. And because
retinoids such as acitretin (Soriatane) can cause severe birth defects,
women must avoid pregnancy for at least three years after taking the
* Methotrexate. Taken orally, methotrexate helps psoriasis by
decreasing the production of skin cells and suppressing inflammation. It
may also slow the progression of psoriatic arthritis in some people.
Methotrexate is generally well tolerated in low doses, but may cause
upset stomach, loss of appetite and fatigue. When used for long periods
it can cause a number of serious side effects, including severe liver
damage and decreased production of red and white blood cells and
* Cyclosporine. Cyclosporine suppresses the immune system and is
similar to methotrexate in effectiveness. Like other immunosuppressant
drugs, cyclosporine increases your risk of infection and other health
problems, including cancer. Cyclosporine also makes you more susceptible
to kidney problems and high blood pressure — the risk increases with
higher dosages and long-term therapy.
* Hydroxyurea. This medication isn't as effective as cyclosporine or
methotrexate, but unlike the stronger drugs it can be combined with
phototherapy. Possible side effects include anemia and a decrease in
white blood cells and platelets. It should not be taken by women who are
pregnant or planning to become pregnant.
* Immunomodulator drugs (biologics). Several immunomodulator drugs
are approved for the treatment of moderate to severe psoriasis. They
include alefacept (Amevive), etanercept (Enbrel), infliximab (Remicade)
and ustekinumab (Stelara). These drugs are given by intravenous
infusion, intramuscular injection or subcutaneous injection and are
usually used for people who have failed to respond to traditional
therapy or who have associated psoriatic arthritis. Biologics work by
blocking interactions between certain immune system cells. Although
they're derived from natural sources rather than chemical ones, they
must be used with caution because they have strong effects on the immune
system and may cause life-threatening infections.
Although doctors choose treatments based on the type and severity of
psoriasis and the areas of skin affected, the traditional approach is to
start with the mildest treatments — topical creams and ultraviolet
light therapy (phototherapy) — and then progress to stronger ones if
necessary. The goal is to find the most effective way to slow cell
turnover with the fewest possible side effects.
In spite of a wide range of options, effective treatment of psoriasis
can be challenging. The disease is unpredictable, going through cycles
of improvement and worsening seemingly at random. Effects of psoriasis
treatments also can be unpredictable; what works well for one person
might be ineffective for someone else. Your skin can also become
resistant to various treatments over time, and the most potent psoriasis
treatments can have serious side effects.
Talk to your doctor about your options, especially if you're not
improving after using a particular treatment or if you're experiencing
uncomfortable side effects. He or she can adjust your treatment plan or
modify your approach to ensure the best possible control of your
Lifestyle and home remedies
Although self-help measures won't cure psoriasis, they may help improve
the appearance and feel of damaged skin. These measures may benefit you:
* Take daily baths. Bathing daily helps remove scales and calm
inflamed skin. Add bath oil, colloidal oatmeal, Epsom salts or Dead Sea
salts to the water and soak for at least 15 minutes. Avoid hot water and
harsh soaps, which can worsen symptoms. Instead, use lukewarm water and
mild soaps that have added oils and fats.
* Use moisturizer. Blot your skin after bathing, then immediately
apply a heavy, ointment-based moisturizer while your skin is still
moist. For very dry skin, oils may be preferable — they have more
staying power than creams or lotions do and are more effective at
preventing water from evaporating from your skin. During cold, dry
weather, you may need to apply a moisturizer several times a day.
* Cover the affected areas overnight. To help improve redness and
scaling, apply an ointment-based moisturizer to your skin and wrap with
plastic wrap overnight. In the morning, remove the covering and wash
away the scales with a bath or a shower.
* Expose your skin to small amounts of sunlight. A controlled amount
of sunlight can significantly improve lesions, but too much sun can
trigger or worsen outbreaks and increase the risk of skin cancer. If you
sunbathe, it's best to try short sessions three or more times a week.
Keep a record of when and how long you're in the sun to help avoid
overexposure. And be sure to protect healthy skin with a sunscreen of at
least 15 SPF, paying careful attention to your ears, hands and face.
Before beginning any sunbathing program, ask your doctor about the best
way to use natural sunlight to treat your skin.
* Apply medicated cream or ointment. Apply an over-the-counter cream
or ointment containing hydrocortisone or salicylic acid to reduce
itching and scaling. If you have scalp psoriasis, try a medicated
shampoo that contains coal tar. For best results, follow label
* Avoid psoriasis triggers, if possible. Find out what triggers, if
any, worsen your psoriasis and take steps to prevent or avoid them.
Infections, injuries to your skin, stress, smoking and intense sun
exposure can all worsen psoriasis.
* Avoid drinking alcohol. Alcohol consumption may decrease the effectiveness of some psoriasis treatments.
Many alternative therapies are available to treat psoriasis, including
special diets, creams, dietary supplements and herbs. Some people claim
these therapies are helpful in treating psoriasis, but most haven't been
Some alternative therapies are deemed generally safe, and may be helpful
in reducing signs and symptoms such as itching and scaling.
* Aloe vera. Taken from the leaves of the aloe vera plant, aloe
extract cream may reduce redness, scaling, itching and inflammation. You
may need to use the cream several times a day for a month or more to
see any improvements in your skin.
* Capsaicin cream. Applied to the affected areas several times a
day, capsaicin cream — an extract from chili peppers — may ease itching
and reduce the severity of psoriasis. You may experience a burning
sensation with the first few applications. Be sure to wash your hands
afterward, so you don't accidentally rub the cream in your eyes.
* Fish oil. Omega-3 fatty acids found in fish oil supplements may
reduce inflammation associated with psoriasis, although results from
studies are mixed. Taking 3 grams or less of fish oil daily is generally
recognized as safe and you may find it beneficial.
If you're considering dietary supplements or other alternative therapy
to treat psoriasis, consult your doctor. He or she can help you weigh
the pros and cons of specific alternative therapies.
Coping and support
Coping with psoriasis can be a challenge, especially if the disease
covers large areas of your body or is in places readily seen by other
people, such as your face or hands. The ongoing, persistent nature of
the disease and the treatment challenges only add to the burden.
Here are some ways to help you cope and to feel more in control:
* Get educated. Find out as much as you can about the disease and
research your treatment options. Understand possible triggers of the
disease, so you can better prevent flare-ups. Educate those around you —
including family and friends — so they can recognize, acknowledge and
support your efforts in dealing with the disease.
* Follow your doctor's recommendations. If your doctor recommends
certain treatments and lifestyle changes, be sure to follow them. Ask
questions if anything is unclear.
* Find a support group. Consider joining a support group with other
members who have the disease and know what you're going through. You may
find comfort in sharing your experience and struggles and meeting
people who face similar challenges. Ask your doctor for information on
psoriasis support groups in your area or online.
* Use cover-ups when you feel it necessary. On those days when you
feel particularly self-conscious, cover the psoriasis with clothing or
use cosmetic cover-up products, such as body makeup or a concealer.
These products can mask redness and psoriasis plaques. They can irritate
the skin, however, and shouldn't be used on open sores, cuts or