Chronic papulosquamous dermatological disorder presenting as raised, reddish pink lesions covered with silvery, opaque scales and well-defined borders. Lesions occur predominantly on the scalp, elbows, knees, groin, and sacrum, although not limited to these areas. May appear as a few spots or involve large areas. Increased ratio of cyclic GMP over cyclic AMP within the dermis stimulates a high cell production rate. Newly generated cells rise to the skin's surface within days, accumulating in thick, crusty patches. The condition afflicts more than six million people in the U.S. of both sexes, all ages, is negatively affected by emotional stress, is not contagious, and has genetic traits. (Patients with Crohn's disease have a seven fold risk increase; chromosome 16 is implicated in both disorders.) Severe cases can be physically painful and emotionally traumatic due to its unsightly appearance. Approximately 10% of psoriasis sufferers develop psoriatic arthritis, a phenomenon unique among skin disorders. Although there is no cure, symptoms can be managed in most instances. The disease may take one of several forms:

• Chronic, plaque-type (most common)
• Guttate
• Psoriatic erythroderma
• Pustular
• Flexural
• Ostraceous

Specific etiology uncertain; several factors are implicated:

• Immune system dysfunction (HLA antigen involvement)
• Genetic traits (portions of chromosomes 16, 17, 20, 6)

Trigger events:

• Emotional stress
• Skin injuries/sunburn
• Streptococcal infection (symptoms sometimes first appear two weeks after strep throat)
• Certain drugs (chloroquine, gold, lithium, beta-blockers)
• Acidic foods

• Familial/genetic predisposition
• Race (incidence highest among Caucasians)
• Immune system diseases (including AIDS)
• Obesity
• Alcoholism
• Streptococcal infections elsewhere in the body
• Skin damage
• Rheumatoid arthritis

Symptoms wax and wane. Manifestations include:

• Raised skin lesions, deep pink with red borders and silvery surface scales; may be cracked and painful
• Blisters oozing aseptic pus (pustular or guttate type—occurs only on palms or plantars)
• Pitted, discolored, and possibly thickened fingernails and/or toenails; may be separated from underlying skin
• Itching in some cases
• Joint pain (psoriatic arthritis) in some cases
• New lesions may appear following injuries to the skin.

• Eczema
• Dermatitis
• Other skin disorders
• Squamous cell carcinoma
• Cutaneous lupus erythematosus
• Intertrigo or candidiasis

Unsightly raised dermal lesions deep pink or red in color with white or silvery scales; pustules on palms and plantars; pitted, discolored nails.

• Elevated cGMP relative to cAMP
• Decreased dermal keratohyalin
• Increased intracellular calcium and calmodulin levels
• Low zinc/high copper levels
• Possible B12, folate, and iron deficiencies
• Possible anemia

• Dermal surface lesions due to abnormally rapid cell growth, deposit, and accumulation
• Abnormal microvasculature dermal permeability

• Skin biopsy, if necessary

Identifying cause of onset in relation to emotional trauma, skin injury, viral/bacterial infection, diet, weight gain may help define treatment options. Although blood tests will not confirm diagnosis, laboratory tests for levels of cGMP/cAMP, HLA antigens, and levels of calcium, zinc, and certain drugs may also help determine mode of treatment, which includes:

• Topical medications
• Systemic drugs
• Light therapy—solar and ultraviolet radiation
• Dietary modification—avoid triggers, lose weight
• Vitamin/mineral supplementation
• Exercise
• Elimination therapy (certain medications and acidic foods)

Reduce epidermal proliferation rate and/or halt the inflammatory process.

Topical creams and lotions:

• Corticosteroids: Reduce inflammation/irritation (use only to begin treatment; prolonged use causes skin thinning, pigment changes, and suppresses the immune system, causing vengeful flare-ups upon cessation.)
• Petroleum jelly: Softens skin and retains moisture
• Salicylic acid ointments: Promote scale shedding
• Capsaicin ointment: Prevents blood vessel development in affected areas; blocks inflammatory skin chemicals; should be used with care, and never on open wounds or sores as it would be very painful
• Calcitriol (or calcipotriene) ointment (vitamin D₃ analogue): May be as effective as corticosteroids with fewer side effects.
• Coal tar ointments/shampoos: Ease discomfort, improve effectiveness of UV light therapy (may cause folliculitis; increased squamous cell carcinoma risk)
• Etretinate: Good response with few side effects (for severe cases unresponsive to other treatments)
• Anthralin: Applied for 30 to 60 minutes only to affected area (irritates healthy skin; stains last several weeks)

Ultraviolet light: Natural sunlight in short increments (sunburn detrimental)

• PUVA: Artificial long-wave light therapy in combination with oral psoralen (photosynthesizing agent), effective in recalcitrant cases (significant carcinogenic risk in long-term treatments)
• UVB: Artificial short-wave light therapy in combination with topical medications such as coal tar (no significant increase in carcinogenic risk factor)
• Liquid nitrogen: freeze moderate-sized lesions

Systemic/Oral drugs (in difficult cases):

• Methotrexate: anticancer drug (long-term use causes hepatic, renal, hematologic toxicity; nausea; vomiting; diarrhea; significant risk of squamous cell and increased risk of metastatic carcinoma)
• Psoralen: With UVB therapy; least toxic oral medication
• Tegison (vitamin A analogue): inhibits rapid skin cell growth, particularly with UV therapy (numerous side effects)
• NSAIDs: for pain/inflammation of psoriatic arthritis

Therapies are aimed at detoxifying the entire body and regulating cGMP/cAMP ratios. Patients often benefit from mind-body therapies and stress management. Exercise increases cAMP and improves overall health. Proper hydration aids in elimination. Herbs and nutrition may be helpful by themselves or as adjunctive therapy.

• Limit alcohol, refined foods, simple sugars, and saturated fats found in meat and dairy as these foods tend to exacerbate this condition. Avoid acidic foods (pineapple, oranges, coffee, tomato) and any allergic foods (wheat, citrus, milk, corn, eggs are the most common).
• Essential fatty acids: omega-3 and omega-6 (oily fish, flaxseed oil, 1,000 mg bid)
• Vitamins: B12 (100 to 1,000 mcg) may need to be intramuscular injections, folate (400 mcg/day), vitamin E (400 to 800 IU/day)
• Minerals: found to be low in patients with psoriasis; zinc (30 mg/day), selenium (200 mcg/day)
• Quercetin: 500 mg tid before meals, decreases cAMP, decreases gut inflammation
• Digestive enzymes facilitate proper protein digestion and should be taken with each meal. This is particularly important as incomplete protein digestion inhibits the formation of cAMP, thus contributing to the cell proliferation which characterizes psoriasis.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Topical creams may alleviate discomfort. Chickweed (Stellaria media) relieves itching, and marigold (Calendula officinalis) speeds healing of open lesions.
• Milk thistle (Silybum marianum) decreases cAMP breakdown, liver protectant
• Yellowdock (Rumex crispus), red clover (Trifolium pratense), and burdock (Arctium lappa) are alteratives.
• Sarsaparilla (Smilax sarsaparilla) binds endotoxins, shown in studies to be effective in psoriasis.
• Coleus forskohlii (tincture, 1 ml tid) increases cAMP, and has been used historically for psoriasis.

Mix equal parts of the above herbs and use 1 cup tea tid or 30 to 60 drops tincture tid. This is especially effective if sipped or taken 5 to 15 minutes before meals to stimulate digestion.

In homeopathic philosophy, treating a skin condition is not beneficial. Constitutional treatment by a homeopathic prescriber who will address the whole person may help. Homeopathic treatment of skin problems can result in an initial worsening of any skin condition before resolution.

Sunlight/ultraviolet light is a beneficial treatment for those with psoriasis. Exposure to the sun or UVB for half an hour daily is a helpful treatment.

Follow-up is important in severe cases, particularly when treatment includes corticosteroids.

Prevention may not be possible, but avoid triggering drugs (lithium, NSAIDs, salicylates, white willow [Salix alba], penicillin, and others). Treatment aims at avoiding flare-ups and lengthening periods of remission. A stressful event often precedes the initial episode, thus stress management techniques often help with successful treatment.

• Secondary infections
• Arthritis
• Serious bowel involvement
• Exfoliate erythrodermatitis
• Rebound after corticosteroids

Aggressive control and treatment usually beget a benign course.

Oral medications and topical creams absorbed into the bloodstream can be damaging to the fetus. Use caution when treating psoriasis.

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