To diagnose psoriasis, you do not require any special tests. Clinical history of the disease and the signs and symptoms give a fairly accurate diagnosis of psoriasis to the experienced dermatologist. The diagnosis is mainly clinical and the doctor rarely requires a skin biopsy to confirm the diagnosis.
Once diagnosed, the dermatologist analyses the various treatment options and chooses one that fits the patient best.
Of course, there are conditions that look similar to psoriasis but the dermatologist through the differential diagnosis process is able to make the diagnosis.
Each type of psoriasis presents in its own distinct way and the dermatologist, besides diagnosing the condition, is also able to diagnose the type.
Skin biopsy procedure and indication
Rarely, a skin biopsy may be required especially when the psoriasis spots or papules have not merged to form a plaque.
The dermatologist takes the scraping of the affected part of the skin after administering a local anesthetic. This is called a shave biopsy and he does it using a razor blade.
Usually, in psoriasis, the dermatologist collects the sample doing a punch biopsy because there is a buildup of skin cells. In this biopsy, he uses a special circular blade to remove the sample
He sends the sample for histopathology to the pathology department, where the trained pathologist examines it under the microscope.
The biopsy helps determine the type of skin psoriasis and to rule out other disorders that can mimic psoriasis.
The findings will reveal a large number of proliferated dry skin cells without the presence of inflammation and infection. Another diagnostic sign of psoriasis will be pinpoint bleeding at the point where the plaques are scrapped. (Auspitz’s sign).
The report of the biopsy is available after 2 to 3 days.
Treatment of Psoriasis
Psoriasis has no cure and the purpose of its treatment is to control its symptoms and reduce the patient’s suffering.
The aim of the treatment is to:
- Stop the excessive proliferation of the skin cells, thereby reducing inflammation and formation of plaques.
- Remove the scales, smoothen, and normalize the skin appearance. This will help improve the quality of life of the patient as much as possible. Very often, treatment cannot completely clear the psoriasis lesions and some amount of erythema may remain.
- Minimize the side effects of the medications used.
Educating the Psoriasis Patient
Though educating the patient does nothing to treat the disease, yet this is an important aspect of treating the psoriasis patient, considering the social stigma attached to this skin condition and the depressive attitude that comes with it.
The dermatologist explains the following points to the patient to ease his psychological symptoms.
- Firstly, it is not contagious.
- Secondly, it is quite common.
- Thirdly, that he or she has to learn to live with it as you cannot cure psoriasis but you can control its symptoms.
- Fourthly, the doctor makes the patient aware of the causes and the factors that can trigger a psoriasis flare-up.
- Fifth, he is also made aware of the risk factors that can make him prone.
- Last but not the least, the patient should know the complications that can arise if due treatment is not taken.
There are three forms of treatments for psoriasis and each has its own indications. Your dermatologist decides on the most suitable treatment for you after taking into consideration three things:
- The type of psoriasis
- Its severity
- The total proportion of the body involved.
There are three options for the dermatologist to choose from to treat psoriasis:
- Topical treatments
- Systemic medications, which include oral and injectable drugs
Topical applications to treat psoriasis consist of creams and ointments that your dermatologist advises applying directly over the psoriasis skin lesions.
Topical psoriasis treatments include:
Topical corticosteroids are anti-inflammatory creams recommended for mild to moderate form of psoriasis. They reduce the inflammation of the skin.
Topical retinoids are a synthetic form of vitamin A. They act by slowing down the overproduction of the skin cells and reduce skin inflammation.
Anthralin is a topical antimitotic prescribed for long-term psoriasis. It works by slowing down the growth of skin cells.
Vitamin D analogue is a synthetic form of vitamin D and different from the oral form. It slows down the production of skin cells and reduces inflammation.
Salicylic acid preparations. Salicylic acid is a keratolytic agent. It works by softening and shedding the outer horny layer of skin.
Bath salts are water-soluble, powdered minerals that you add to your bathwater. This helps soothe the skin and the symptoms.
Moisturizers in an ointment base are more useful than cream-based ones to treat psoriasis. They reduce the itching, scaling, and dryness of the skin,
UVA and UVB
Phototherapy is the use of artificial light (ultraviolet rays A and B) to control psoriasis symptoms. It is mainly used to treat psoriasis that is extensive. The treatment involves several sessions per week carried out in a hospital or specialized centers by a dermatologist.
Your dermatologist may even suggest that you carry out these phototherapy sessions at your home, for which UV lightboxes and bulbs are available.
PUVA is a specialized type of phototherapy that involves treating psoriasis with phototherapy and a photosensitization drug. The light sensitizing drug in PUVA is called psoralen. The rationale behind the use of psoralen is that it makes the psoriasis skin more responsive to UVA light, thereby allowing smaller doses of UVA to be required.
Systemic medications for psoriasis
If your psoriasis does not respond satisfactorily to topical treatment and phototherapy, your dermatologist will put you on systemic drugs, which may be oral and/or parenteral.
Methotrexate belongs to a class of drugs called antimetabolites and is immunosuppressant. It is an oral drug and indicated in the treatment of severe forms of psoriasis.
It suppresses the action of the T-cells of the immune system, which are responsible for the inflammatory reaction seen in psoriasis.
Due to its depressive action on the T cells, it inhibits the proliferation of the skin cells and prevents the flare-up of the inflammation.
It is used in small doses in these autoimmune diseases and side effects in such doses include fever with chills, fatigue, dizziness, and recurrent infections.
Long-term use can cause serious side effects, which include liver toxicity and decreased production of red and white blood cells.
Cyclosporine is another strong immunosuppressant oral drug used to treat psoriasis that is widespread and difficult to treat.
By is immunosuppressant action, it suppresses the inflammation characteristic of psoriasis and reduces its symptoms.
Side effects include recurrent infections, increased blood pressure, and kidney damage.
Retinoids. Acitretin is an oral second-generation retinoid and a synthetic vitamin A compound, which helps to reduce psoriasis symptoms by regulating the growth of the skin cells by modulating the immune system.
Long-term use can cause serious side effects, which include loss of night vision, chest pain, shortness of breath, difficulty in speech.
It is for this reason that your doctor will ask you to stop taking this medication once there is remission.
Biologics, the latest to arrive on the scene in the treatment of psoriasis and other autoimmune diseases, are injectables administered by subcutaneous or intramuscular routes or by infusion.
These drugs also alter the pathway of the immune system and check the inflammatory response, thereby improving the psoriasis symptoms.
They are manufactured proteins and have a very powerful action on the immune system targeting only its specific parts.
They act on the T-cells and the proteins in the immune system, such as tumor necrosis factor-alpha (TNF-alpha), interleukin 17-A, or interleukins 12 and 23.
Cost of psoriasis treatment
The cost of systemic psoriasis therapy is rising very fast and the biological medicines can be costly. Here are the annual approximate expenses for the treatment of psoriasis.
- Systemic psoriasis therapies can cost between $1200 (methotrexate) to $27500 (two 12 week courses with alefacept)
- The cost of phototherapy ranges from $3000 to $7000.
- The cost of treatment with biology medicines ranges from $18,400 to $27,500.
How to tell if your treatment is working?
There are various types of treatments to cure psoriasis. Your dermatologist will try the topical applications first in the mild to moderate cases. If that does not produce satisfactory results, your doctor will put you on phototherapy and PUVA.
Systemic therapy remains the last line of treatment and is reserved for severe cases. The drugs used are not without serious side effects and therefore their use is over the short term. Once remission is attained, these drugs are stopped.
You are educated on the factors that cause and trigger a psoriasis flare-up and certain factors that trigger one.
Whichever treatment your doctor adopts you should continue using it for three months to see results.
The recent guidelines suggest aiming for the most clearance possible. The objective of any line of treatment is to bring down the skin plaques on 1% or less of your body after three months of treatment.
If that does not happen, your doctor will promote the line of treatment to a stronger group of therapy.
How long does it take?
Psoriasis is reputably unpredictable. How it will respond to treatment in a particular person is impossible to predict. Therefore, it’s impossible to know who will have a remission and how long it will last.
With UVB phototherapy, it often takes at least two or three months of regular exposure for psoriasis to clear up.
According to the National Psoriasis Foundation, in about 75 percent of people undergoing PUVA treatment, psoriasis clears up for almost a year. On average, it takes about 25 sessions of PUVA therapy to clear the skin.
With methotrexate, more than 80 percent of patients see some improvement within two to three months.
Cyclosporine is usually prescribed for patients with severe psoriasis where other drugs have failed or the patient cannot take them. Usually, it clears up the psoriasis patches within six weeks.
Acitretin (Retinoid) is used to treat plaque, erythrodermic, and pustular psoriasis, in cases where other therapies have not succeeded. It usually produces improvement in symptoms within two to four months.
At times, treatment can completely clear the skin and the psoriasis symptoms and produce a remission, which can last for months or years. Most remissions, however, last from 1 to 12 months.
In the treatment of psoriasis, therapies that have the least side effects are preferred. However, in more severe resistant psoriasis, therapies with more serious side effects have to be deployed.
Medications with serious side effects are reserved for the severe and unresponsive forms of psoriasis. This treatment pattern is called the psoriasis treatment ladder.
This step involves using topical treatment using psoriasis creams and ointments.
If the topical treatment does not give the desired results, the psoriasis is treated with phototherapy.
The third step involves the use of systemic treatment in which oral pills and injections and biologic medications are used to treat psoriasis.