E-Newsletter July 2008
Psoriasis- A multi-miasmatic monster
Dr. Samir Chaukker
Psoriasis is a disorder which affects the skin and joints. It commonly causes red scaly patches to appear on the skin. The scaly patches caused by psoriasis, called psoriatic plaques, are areas of inflammation and excessive skin production. Skin rapidly accumulates at these sites and takes a silvery-white appearance. Plaques frequently occur on the skin of the elbows and knees, but can affect any area including the scalp and genitals. Psoriasis is hypothesized to be immune-mediated and is not contagious.
Psoriasis is a common skin disease that affects the life cycle of skin cells. Normally, new cells take about a month to move from the lowest skin layer where they're produced, to the outermost layer where they die and flake off. With psoriasis, the entire life cycle takes only days. As a result, cells build up rapidly, forming thick silvery scales and itchy, dry, red patches that are sometimes painful.
Psoriasis is a chronic non-contagious skin disorder. It can affect any part of the body but most often occurs on scalp, elbows, knees, hands, feet and genitals. It may present itself with severe itching and physical discomfort. Although there are many types of psoriasis, the most common type is characterized by raised and thickened red patches covered with silvery scales. Many skin disorders may portray such symptoms, but three main features which differentiate psoriasis from other skin disorders are: psoriasis has well-defined borders. The surface has silvery scales that easily come off and the skin under the scales has a shiny red appearance
Half of the cases of psoriasis show some changes in their nails .There may be pitting, yellow - pink discoloration or complete loss of nail due to the involvement of nail matrix and nail-bed.
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 becomes worse.
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. And self-care measures, such as using a nonprescription cortisone cream and exposing your skin to small amounts of ultraviolet light, can improve your psoriasis symptoms.(5)Ten to fifteen percent of people with psoriasis have psoriatic arthritis.
The cause of psoriasis is not known, but it is believed to have a genetic component. Several factors are thought to aggravate psoriasis. These include stress, excessive alcohol consumption, and smoking. Individuals with psoriasis may suffer from depression and loss of self-esteem. As such, quality of life is an important factor in evaluating the severity of the disease. There are many treatments available but because of its chronic recurrent nature psoriasis is a challenge to treat.(1)
Traditionally psoriasis was thought to be a condition of the upper most layer of the skin (the epidermis), but recent research has found that the changes in the skin begin in the immune system when certain immune cells (T cells) are triggered and become overactive. The T cells produce inflammatory chemicals, and act as if they were fighting an infection or healing a wound, which leads to the rapid growth of skin cells causing psoriatic plaques to form. You may therefore hear psoriasis being described as an “auto-immune disease” or “immune-mediated condition”. It is not yet clear what triggers the immune system to act in this way.
Around 30% of people with psoriasis have a family history of the condition, and certain genes have been identified as being linked to psoriasis. However, many genes are involved and even if the right combination of genes has been inherited, psoriasis may not appear. A trigger is required for psoriasis to develop and this could be a throat infection, injury to the skin, certain drugs and physical or emotional stress.
Psoriasis may be one of the oldest recorded skin conditions. It was probably first described around 35 AD. Some evidence indicates an even earlier date. Yet, until recently, little was known about psoriasis.
While scientists still do not fully know what causes psoriasis, research has significantly advanced our understanding. One important breakthrough began with the discovery that kidney-transplant recipients who had psoriasis experienced clearing when taking cyclosporine. Since cyclosporine is a potent immunosuppressive medication, this indicates that the immune system is involved.
Immune Mediated. Researchers now believe that psoriasis is an immune-mediated condition. This means the condition is caused by faulty signals in the body’s immune system. It is believed that psoriasis develops when the immune system tells the body to over-react and accelerate the growth of skin cells. Normally, skin cells mature and are shed from the skin’s surface every 28 to 30 days. When psoriasis develops, the skin cells mature in 3 to 6 days and move to the skin surface. Instead of being shed, the skin cells pile up, causing the visible lesions.
Genes. Researchers have identified genes that cause psoriasis. These genes determine how a person’s immune system reacts. These genes can cause psoriasis or another immune-mediated condition, such as rheumatoid arthritis or type 1 diabetes. The risk of developing psoriasis or another immune-mediated condition, especially diabetes or Crohn’s disease, increases when a close blood relative has psoriasis.
Family History. Some people who have a family history of psoriasis never develop this condition. Research indicates that a “trigger” is needed. Stress, skin injuries, a strep infection, certain medications, and sunburn are some of the known potential triggers. Medications that can trigger psoriasis are anti-malarial drugs, beta-blockers (medication used to treat high blood pressure and heart conditions), and lithium. Dermatologists have seen psoriasis suddenly appear after a person takes one of these medications, gets a strep infection, or experiences another trigger.
Psoriasis 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 disabling.
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.
Different forms of psoriasis
There are five types of psoriasis.
1) Plaque: Most common form of the disease
2)Guttate: Appears as small red spots on the skin
3) Inverse: Occurs in armpits, groin and skin folds
4) Pustular: White blisters surrounded by red skin
5) Erythrodermic: Intense redness over large areas
Psoriasis is a very diverse skin disease that appears in a variety of forms. Each form has distinct characteristics. Typically, people have only one type of psoriasis at a time, but occasionally two or more different types of psoriasis can occur at the same time. Psoriasis can also occasionally change from one form to another. Trigger factors may "convert" some forms of psoriasis, such as plaque, to another form, such as pustular. Generally, one type of psoriasis will clear and then another form of psoriasis will appear later.
Plaque psoriasis is the most prevalent form of the disease. About 80 percent of all those who have psoriasis have this form. Its scientific name is psoriasis vulgaris (vulgaris means common). It is characterized by raised, inflamed, red lesions covered by a silvery white scale. It is typically found on the elbows, knees, scalp and lower back.
Guttate psoriasis is a form of psoriasis that often starts in childhood or young adulthood. The word guttate is from the Latin word meaning "drop." This form of psoriasis resembles small, red, individual spots on the skin. Guttate lesions usually appear on the trunk and limbs. These spots are not usually as thick as plaque lesions.
Guttate psoriasis often comes on quite suddenly. A variety of conditions have been known to bring on an attack of guttate psoriasis, including upper respiratory infections, streptoccocal infections, tonsillitis, stress, injury to the skin and the administration of certain drugs (including antimalarials and beta-blockers). A streptococcal infection of the throat (strep throat) is a common guttate psoriasis trigger. Strep throat can be present without symptoms and can still cause a flare of guttate psoriasis. Guttate psoriasis may persist despite clearance of the strep infection. Some doctors prescribe antibiotics to help prevent an occurrence of an infection that can cause the outbreak of guttate psoriasis.
Inverse psoriasis is found in the armpits, groin, under the breasts, and in other skin folds around the genitals and the buttocks. This type of psoriasis first shows up as lesions that are very red and usually lack the scale associated with plaque psoriasis. It may appear smooth and shiny. Inverse psoriasis is particularly subject to irritation from rubbing and sweating because of its location in skin folds and tender areas. It is more common and troublesome in overweight people and people with deep skin folds.
Erythrodermic psoriasis is a particularly inflammatory form of psoriasis that often affects most of the body surface. It may occur in association with von Zumbusch pustular psoriasis. It is characterized by periodic, widespread, fiery redness of the skin. The erythema (reddening) and exfoliation (shedding) of the skin are often accompanied by severe itching and pain.
Erythrodermic psoriasis causes protein and fluid loss that can lead to severe illness. Edema (swelling from fluid retention), especially around the ankles, may also develop along with infection. The body's temperature regulation is often disrupted, producing shivering episodes. Infection, pneumonia and congestive heart failure brought on by erythrodermic psoriasis can be life threatening. People with severe cases of this condition often require hospitalization.
Known triggers of erythodermic psoriasis include abrupt withdrawal of systemic treatment; the use of systemic steroids (cortisone); an allergic, drug-induced rash that brings on the Koebner response (a tendency for psoriasis to appear on the site of skin injuries); and severe sunburns.
This will depend on the type of psoriasis that you have, and on its severity. Whatever treatment you use it is vitally important to use a moisturiser to make the skin more comfortable. There are four categories of treatments:
1. Topical therapies are treatments that are applied directly to the skin. They are available as creams, lotions, ointments, mousse and gels. Most people with psoriasis will use topical treatments to control the condition. The different categories of topical treatments are: -
· Vitamin D analogues
· Coal tar preparations
· Topical steroids
· Vitamin A analogues
Should your psoriasis be particularly widespread or not responding to topical treatments you may be referred to a Dermatologist who can prescribe the following treatments:
2. Phototherapy is the term used for treatment with ultraviolet light. There are two types of ultraviolet (UV) light that can be used to treat psoriasis, UVB and UVA. Treatment with UVA requires the use of a chemical agent (either in tablet or bath form) called psoralen. Psoralens make the skin more sensitive to UVA. This treatment is referred to as PUVA therapy. Treatment with UVB does not need psoralens.
You will be required to attend the phototherapy centre 2 or 3 times a week for several weeks if you are receiving UV therapy.
3. Systemic medication refers to treatments you take into your body e.g. tablets. However, they all have potential risks and so are reserved for people with moderate to severe psoriasis. The four main systemic medications used in the UK are:
· Methotrexate - slows down the rate at which the skin cells are dividing in psoriasis
· Ciclosporin - suppresses the immune system
· Acitretin – slows down the rate at which skin cells are dividing in psoriasis, and calms inflammation
· Hydroxycarbamide – also slows down the rate at which the skin cells are dividing in psoriasis.
These treatments will be discussed at length with you should your dermatologist feel you would benefit from taking them. You will require ongoing monitoring with blood tests and blood pressure checks, and some tablets cannot be prescribed if you are taking other medications.
4. Biological injections are new treatments available to treat severe psoriasis that has not responded to any of the aforementioned treatments. They work by blocking the action of certain immune cells (T cells) or the chemicals released by them, which play a part in causing psoriasis.
Lifestyle and home remedies(5)
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, oiled 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 make your symptoms worse. 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 cortisone. Apply an over-the-counter cortisone cream 0.5 percent or 1 percent, for a few weeks when your symptoms are especially bad.
§ 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
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 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 unhealed lesions.
Homoeopathic Management of psoriasis
Firstly, one needs to know that research shows that Homoeopathic medicines work by optimising our defence mechanisms. Psoriasis is a result of an overreaction of an immune response, and homeopathy cures it by optimising the immune over-response. It does not suppress the immune system. So, homoeopathic healing is not a miracle or a lucky exception but a fact of biology; the result of the optimum utilisation of the body’s natural healing system which is curative and non-suppressive in nature.
Secondly, it is important to realise that the statement by the conventional system of medicine that psoriasis cannot be permanently cured is only their own opinion, based according to the results achieved with their treatment.
The safety aspect also strengthens the case for homoeopathic medicines to be used for treating psoriasis. While using them, the patient is not exposed to the risk of toxicity as homeopathic medicines are highly diluted and side-effects are very uncommon.
Homoeopathy for psoriasis
It is very clear from the above discussion that psoriasis is not so simple to prescribe for. So, it requires a lot of detailed study of the patient before anything can be prescribed. It requires a deep constitutional analysis. The history of the disease, the family medical history, physical and mental characteristics of the patient, the likes and dislikes, medication details are all taken into consideration. This approach stands in consonance with the homoeopathic convention: Treat the patient, not the disease.
Still there are some drugs which come up commonly after detailed case taking and individualizing the patient. They are given below to serve as guides to all of us Homoeopaths and not to be used as specifics.
Arsenicum album: People likely to respond to this remedy usually are anxious, restless, and compulsively neat and orderly. They are often deeply chilly, experience burning pains with many physical complaints, and become exhausted easily. The skin is dry and scaly and may tend to get infected. Scratching can make the itching worse, and applying heat brings relief.
Arsenic iod: Dry, scaly, itching. MARKED EXFOLIATION OF SKIN IN LARGE SCALES, leaving a raw exuding surface beneath.
Calcarea carbonica: This remedy is suited to people who are easily fatigued by exertion, sluggish physically, chilly with clammy hands and feet, and often overweight. Skin problems tend to be worse in winter. Typically solid and responsible, these people can be overwhelmed by too much work and stress. Anxiety, claustrophobia, and fear of heights are common. Cravings for sweets and eggs are often also seen when Calcarea is needed.
Graphites: People needing this remedy often have a long-term history of skin disorders. The skin looks tough or leathery skin with cracks and soreness. Itching is often worse from getting warm, and the person may scratch the irritated places till they bleed. Trouble concentrating, especially in the morning, is also often seen when this remedy is needed.
Mercurius solubilis: People who seem introverted and formal—but are very intense internally, with strong emotions and impulses—may benefit from this remedy. They tend to have swollen lymph nodes and moist or greasy-looking skin, and are very sensitive to changes in temperature. The areas affected by psoriasis may become infected easily.
Mezereum: A person who needs this remedy usually is serious, and often feels strong anxiety in the region of the stomach. Scaly plaques may itch intensely, thickening or crusting over if the person scratches them too much. Cold applications relieve the itching (although the person feels generally chilly and improves with warmth). People who need this remedy often have a craving for fat, and feel best in open air.
Petroleum: This remedy is often indicated for people whose physical problems are aggravated by stressful emotional experiences. It is especially suited to individuals with extremely dry skin, and problems that involve the palms and fingertips. The person may feel a cold sensation after scratching, and the skin is easily infected and may look tough and leathery. Itching will be worse at night, and from getting warm in bed. People who need this remedy may also have a tendency toward motion sickness.
Rhus toxicodendron: When this remedy is indicated for a person with psoriasis, the skin eruptions are red and swollen, and often itch intensely. Hot applications or baths will soothe the itching—and also muscle stiffness, toward which these people often have a tendency. The person is restless, and may pace or constantly move around. A craving for cold milk is often seen when a person needs this remedy.
Sepia: This remedy may be helpful to a person who feels dragged out and irritable, often with little enthusiasm for work or family life. The person’s skin may be look dry and stiff. Psoriasis may appear in many places on the body, including the nails and genitals. Signs of hormonal imbalance are often seen (in either sex), and problems with circulation are common. Exercise often helps this person’s energy and mood.
Staphysagria: This remedy may be helpful to individuals whose psoriasis has developed after grief or suppressed emotions. Any part of the body can be involved but the scalp is often affected. People who need this remedy often seem sentimental, meek and quiet, and easily embarrassed — but often have a strong internal anger or deeply-buried hurt.
Sulphur: Intensely burning, itching, inflamed eruptions that are worse from warmth and bathing suggest a need for this remedy. Affected areas often look bright red and irritated, with scaling skin that gets inflamed from scratching. This remedy is sometimes helpful to people who have repeatedly used medications to suppress psoriasis (without success).