Psoriasis
Psoriasis is an immune-mediated inflammatory skin disorder. The underlying immune dysfunction is thought to result from the complex interplay between genetic and environmental factors.
Some patients with psoriasis may have a family member who is also affected with psoriasis. A flare-up of psoriasis can be triggered by stress, injury to the skin, infections, and certain medications. Psoriasis has also been found to be associated with heart disease and diabetes mellitus.
The most common indication is the presence of raised, red patches (plaques) on the skin, covered with silvery or white scales, primarily appearing on the elbows, knees, scalp, lower back, feet, nails, and genital regions. Other signs and symptoms include:
- Skin that feels burning or itchy
- Dry, cracked skin that bleeds
- Skin pain or soreness
- Pitted (dented) or discoloured nails
The severity of symptoms can range from mild to severe, with some individuals experiencing occasional flare-ups while others have persistent symptoms.
For some patients, the inflammatory process underlying psoriasis can also affect the joints. This condition is called psoriatic arthritis and presents as painful, stiff joints.
There are several types of psoriasis, classified based on their distinctive appearance and symptoms.
- Chronic Plaque Psoriasis – The most common type of psoriasis, presenting as pink, raised, scaly patches on the scalp, knees, elbows, and torso. Patches may appear symmetrically on both sides of the body and cause pain, cracking, or bleeding.
- Pustular Psoriasis – A rare type of psoriasis, characterised by non-infectious pus-filled blisters (pustules) surrounded by red, inflamed skin. This type of psoriasis typically appears on the hands and feet and can be triggered by certain medications, infections, or stress.
- Erythrodermic Psoriasis – Rare but severe and can be life-threatening, this form of psoriasis results in widespread skin redness and shedding, often with intense pain, difficulty maintaining proper body temperature, and an increased heart rate. Triggers include bad sunburns or certain medications.
- Guttate Psoriasis – This type of psoriasis manifests as small, teardrop-shaped skin patches, typically appearing on the torso or limbs. It is commonly observed in children and young adults and is often triggered by bacterial or viral infections, such as Streptococcal throat infection.
- Nail Psoriasis – This condition causes various changes in the nails, including pitting, discolouration, thickening, or separation from the nail bed.
Psoriasis can be mild, moderate or severe. Those patients with rashes covering less than 3% of their body are considered to have mild disease, those with 3–10% covered are considered moderate. These categories are useful for deciding which treatments may be most appropriate for the patient. However, other deciding factors in selecting treatments such as the impact of psoriasis on the quality of life need to be taken into consideration too.
Although psoriasis is not curable, several treatment options are available to effectively manage the disease. Treatments for psoriasis can range from topical creams to phototherapy, tailored based on the severity of the condition and the type of psoriasis.
Mild cases of psoriasis are usually treated with topical creams such as calcipotriol and calcipotriol/betamethasone dipropionate. Phototherapy using narrow-band ultraviolet B (UVB) is a good adjunctive treatment. This treatment is available in our clinic. For more severe cases of psoriasis, systemic or oral medications may be necessary. These include methotrexate, cyclosporine and acitretin. Like many other drugs, the effectiveness of these medications must be balanced with the side effects that they may cause.
A newer oral medication called Apremilast, is also used to treat moderate to severe psoriasis. This is a PDE4 inhibitor that belongs to a class of selective immunosuppressant agents.
Biologic treatments or “biologics” are a new class of medication that has revolutionised psoriasis treatment. They are protein-based drugs derived from living cells in the laboratory and have been in use to treat psoriasis in the last decade. This class of medication offers hope to psoriasis patients who have failed other treatments or have experienced side effects from their previous treatments. These medications are given as injections via the subcutaneous or intravenous route and help to reduce the inflammatory process that is driving the replication of skin cells and the destruction of the joints.
In psoriasis, a protein in the immune system called tumour necrosis factor is known to be present at increased levels and this leads to inflammation. Tumour necrosis factor - alpha (TNF-α) inhibitors are a big group of biologics that bind to the excess TNF-α to decrease the inflammation process. Examples are Etanercept, Adalimumab and Infliximab. Another class of biologics works against interleukin 12/23 which are associated with psoriatic inflammation. An example of this class of biologics is Ustekinumab which specifically targets and blocks the action of IL-12 and IL-23.
The latest biologics that are available in Singapore are Secukinumab (Cosentyx®) and Ixekizumab (Taltz®). Guselkumab (Tremfya®) and Risankizumab (Skyrizi®). Secukinumab is a human monoclonal antibody that selectively binds to interleukin-17A (IL-17A). IL-17A is involved in the development of psoriasis. Ixekizumab is a humanised monoclonal antibody against IL-17A. Guselkumab is a human monoclonal antibody that binds to IL-23 with high specificity and affinity. Risankizumab is a humanised antibody against IL-23. All these biologics interrupt the inflammatory cycle of psoriasis leading to improvement of the condition.
These injections are all available in the clinic. Patients are assessed for their suitability for biologics based on their clinical history, concurrent medical issues, and lifestyle needs.
In addition to medical treatments, lifestyle changes and self-care measures can help improve symptoms and prevent psoriasis flare-ups. The following are some tips for managing psoriasis:
- Maintain Skin Moisture – Moisturise regularly to ensure skin hydration and reduce discomfort, scaling, and inflammation.
- Avoid Scratching – Resist the urge to scratch the affected areas to prevent irritation, infection, or new skin lesions from forming.
- Steer Clear of Fragrances – Opt for fragrance-free or hypoallergenic skincare products to minimise irritation.
- Adopt Healthy Lifestyle Practices – Maintain an optimal weight, consume a balanced diet, and engage in physical activity.
- Reduce Stress – Patients can manage stress levels by engaging in physical exercises and practising relaxation techniques such as deep breathing or meditation.
- Refrain from Drinking Alcohol and Smoking – Limit alcohol consumption and quit smoking to avoid aggravating psoriasis symptoms and increasing the risk of skin damage.
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