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What is Psoriasis?

Psoriasis[1] is caused by an immune system disorder involving a type of white blood cell called a T lymphocyte or T cells[2]. These T cells usually travel through the body doing their job of fighting off viruses and other foreign substances, but with psoriasis patients, they attack healthy skin cells instead. It causes increased and faster production of healthy skin cells and more T cells to build up on the skin’s surface as scales and patches that are associated with this condition.

Psoriasis is a long-lasting, noncontagious https://en.wikipedia.org/wiki/Psoriasis – cite_note-Lancet2015-4 autoimmune disease characterised by raised areas of abnormal skin. These areas are red (or purple on some people with darker skin) and are dry, itchy, and scaly. The symptoms of psoriasis can worsen as a result of certain triggers, which may include:

  • Infections
  • Injury to the skin
  • Stress
  • Smoking
  • Alcohol consumption
  • Certain medications

People with psoriasis can prevent a flare-up of symptoms by avoiding the above triggers.

The Heartbreak of Psoriasis
Picture Credit:The Heartbreak of Psoriasis” by tomswift46 (Hi Res Imaes for Sale) is licensed under CC BY-NC-ND 2.0.

Types
There are several different types of psoriasis, each of which causes different symptoms. While patients usually only have one type of psoriasis at any given time, another type can appear once the first has cleared. The types include:

  • Plaque psoriasis – is the most common type of psoriasis that affects between 80 to 90 per cent of psoriasis patients, causing raised red lesions covered with silvery-white scales, usually appearing on the elbows, knees, scalp and back.
  • Guttate psoriasis[3] – usually begins during childhood or early adulthood and causes small red spots to appear on the skin of the torso, arms and legs as a result of a bacterial infection such as tonsilitis or strep throat[4].
  • Pustular psoriasis – causes white blisters filled with pus surrounded by red areas of skin, often triggered by medications, UV light, pregnancy or infection and is most common in adults.
  • Erythrodermic psoriasis is the least common type of psoriasis that often causes redness and scaling across the whole body and may lead to serious illness if untreated.
  • Inverse psoriasis – develops within the armpits, groin, under the breasts or other skin folds, causing bright red lesions due to irritation from rubbing and sweating. It is most common in obese and overweight patients.
  • Nail psoriasis[5] – produces a variety of changes in the appearance of finger and toenails. These changes include discolouring under the nail plate, pitting of the nails, lines going across the nails, thickening of the skin under the nail, and the loosening (onycholysis) and crumbling of the nail.

Why Psoriasis happens[6]
People with psoriasis have an increased production of skin cells. Skin cells are normally made and replaced every three to four weeks, but in psoriasis, this process only takes about three to seven days. The resulting build-up of skin cells is what creates the patches associated with psoriasis.

Although the process is not fully understood, it is thought to be related to a problem with the immune system – your body’s defence against disease and infection – but it attacks healthy skin cells by mistake in people with psoriasis.

Psoriasis can run in families, although the exact role genetics plays in causing psoriasis is unclear. The condition is not contagious, so it cannot be spread from person to person. Many people’s psoriasis symptoms worsen because of a certain event, known as a trigger. Possible triggers of psoriasis include an injury to your skin, throat infections and using certain medicines.

Symptoms
Symptoms may vary and depend on each patient’s personal condition but often include:

  • Red patches of skin covered with silvery scales
  • Crusting
  • Dry, cracked skin
  • Itching or burning
  • Soreness
  • Thickened nails

Fingernails and toenails are affected in most people with psoriasis at some time. This may include pits in the nails or changes in nail colour.[7] Many cases of psoriasis are merely a cosmetic annoyance, but some also cause severe pain, especially when associated with arthritis. Symptoms usually come and go as psoriasis is a cyclic disorder with remissions and flare-ups throughout the patient’s life. Psoriasis patches can range from a few spots of dandruff-like scaling to major eruptions that cover large areas.

Facts & Figures

  • There is no known cure for psoriasis, but various treatments can help control the symptoms. These treatments include steroid creams, vitamin D3 cream, ultraviolet light, and immunosuppressive drugs, such as methotrexate.[8]
  • About 75% of skin involvement improves with creams alone.
  • The disease affects 2–4% of the population.[9]
  • Men and women are affected with equal frequency.[10]
  • The disease may begin at any age but typically starts in adulthood.
  • Psoriasis is generally thought to be a genetic disease triggered by environmental factors[11].
  • Symptoms often worsen during winter and with certain medications, such as beta-blockers or Non-steroidal anti-inflammatory drugs (NSAIDs)[12].
  • Psoriasis is associated with an increased risk of psoriatic arthritis, lymphomas, cardiovascular disease, Crohn’s disease, and depression.[13] Psoriatic arthritis affects up to 30% of individuals with psoriasis[14].
  • 70% of people who develop psoriatic arthritis first show signs of psoriasis on their skin, 15% develop skin psoriasis and arthritis simultaneously, and 15% develop skin psoriasis following the onset of psoriatic arthritis[15]. Psoriatic arthritis can develop in people with any level of severity of psoriatic skin disease, ranging from mild to very severe[16].
  • Psoriatic arthritis tends to appear about ten years after the first signs of psoriasis[17]. For most people, this is between the ages of 30 and 55, but the disease can also affect children. The onset of psoriatic arthritis symptoms before symptoms of skin psoriasis is more common in children than adults[18].
  • More than 80% of patients with psoriatic arthritis will have psoriatic nail lesions characterised by nail pitting, separation of the nail from the underlying nail bed, ridging and cracking, or, more extremely, loss of the nail itself (onycholysis)[19].
  • Both sexes are equally affected by this condition. Like psoriasis, psoriatic arthritis is more common among Caucasians than African or Asian people[20].

Types of Treatment[21]
Most people who have psoriasis will consult with their GP in the first instance, who will help treat them. The GP may recommend consultation with a Dermatologist. Treatment will depend on the severity of psoriasis, and not all treatments will work. Treatments usually fall within three categories:

  • Topical – Creams and ointments are often good for scalp psoriasis
  • Phototherapy – Exposing your skin to certain types of ultraviolet light.
  • Systematic – Oral and injected medications that work throughout the body.

Your GP and Dermatologist will be able to determine which is the best treatment for you and discuss a treatment regime.

The so-called ‘difficult-to-treat sites’ encompass the face, flexures, genitalia, scalp, palms and soles and are so-called because psoriasis at these sites may have especially high impact, resulting in functional impairment requiring particular care when prescribing topical therapy and can be resistant to treatment. Your medical professional will consider all factors before arriving at a specific treatment to suit the form of psoriasis you have, its location, and its severity.

What if those psoriasis treatments don’t work?[22]
If psoriasis doesn’t improve, your healthcare provider may recommend one of these treatments:

  • Light therapy: UV light at specific wavelengths can decrease skin inflammation and help slow skin cell production.
  • PUVA: This treatment combines a medication called psoralen with exposure to a special form of UV light.
  • Methotrexate: Providers sometimes recommend this medication for severe cases. It may cause liver disease. If you take it, your provider will monitor you with blood tests. You may need periodic liver biopsies to check your liver health.
  • Retinoids: These vitamin A-related drugs can cause side effects, including birth defects.
  • Cyclosporine: This medicine can help severe psoriasis. But it may cause high blood pressure and kidney damage.
  • Immune therapies: Newer immune therapy medications work by blocking the body’s immune system so it can’t jumpstart an autoimmune disease such as psoriasis.

Saltwater may contain certain nutrients, have antibacterial properties, and work to exfoliate the skin, which may benefit skin health. However, there is little scientific evidence to support its use in skin care. Seawater may contain beneficial nutrients, such as magnesium, potassium, and zinc, and have antibacterial properties. Soaking in mineral salt water may help relieve psoriasis and other skin conditions.[23]

Phototherapy or light therapy is typically prescribed by a dermatologist and involves exposing the skin to ultraviolet light regularly and under medical supervision. Treatments can be done in a health care provider’s office or psoriasis clinic or at home with a phototherapy unit. The key to success with light therapy is consistency.[24]

Scalp Psoriasis[25]
Scalp psoriasis is a common skin disorder that makes raised, reddish, often scaly patches. It can pop up as a single patch or several patches and can even affect your entire scalp. It can also spread to your forehead, the back of your neck, or behind and inside your ears.

word-image-3251-3
Scalp Psoriasis. Picture Credit: Scalp Treatment” by UMHealthSystem is licensed under CC BY-NC-SA 2.0.

You can’t catch scalp psoriasis (or indeed any form of psoriasis) from another person. As with other types of psoriasis, nobody knows what causes it, but doctors put it down to a problem with the immune system that causes skin cells to grow too quickly and build up into patches. If it runs in your family, you may be more likely to get scalp psoriasis.[26]

Scalp psoriasis can be mild and almost unnoticeable, but it can also be severe, last for a very long time, and cause thick, crusted sores. Intense itching can affect sleep and everyday life, and scratching a lot can lead to skin infections and hair loss. Scalp psoriasis is a type of plaque psoriasis and can occur on parts or all of the scalp. It causes patches of skin covered in thick scales.

The amount of time spent in hot showers or the bath or spending too much time in water can sometimes cause your scalp to become dry and flaky and make the skin extremely itchy.

At least half of the people with psoriasis have it on their scalp. The skin cells on your scalp grow too quickly and make powdery or thick scales called plaques. The areas around them can be red and itchy.[27]

Symptoms
Is it dandruff or scalp psoriasis – both may be characterised by flakes, but scalp psoriasis couldn’t be any more different from dandruff.

Symptoms of mild scalp psoriasis might include only slight, fine scaling but the symptoms of moderate to severe scalp psoriasis include:

  • Scaly, red, bumpy patches
  • Silvery-white scales
  • Dandruff-like flaking
  • Dry scalp and hair loss
  • Itching
  • Burning or soreness

Hair Loss
Scalp psoriasis itself doesn’t cause hair loss per se, but scratching a lot or very robustly, picking at the scaly spots, harsh treatments, and the stress that goes along with the condition can lead to temporary hair loss. Fortunately, the hair usually grows back after your skin clears.

Treatment
Over-the-counter products for the treatment of scalp psoriasis often contain one of two medications: either salicylic acid (which helps to loosen the affected scaly area so that it can be gently washed away) or coal tar.

Prescription products for scalp psoriasis may have higher concentrations of either or both of these, as well as several medically-approved medications, such as:

  • Anthralin, an older prescription medication
  • Antimicrobials, which treat bacterial or yeast infections that can come with scalp psoriasis
  • Calcipotriene (a strong derivative (albeit different form) of vitamin D)
  • Calcipotriene and betamethasone dipropionate (a vitamin D derivative combined with a strong steroid)
  • Other topical steroids
  • Tazarotene (a derivative of vitamin A)

Vitamin D benefits and uses for psoriasis[28]
Vitamin D possesses different health benefits that can help treat several types of psoriasis, including scalp psoriasis. A 2011 study[29] found that vitamin D can strengthen the immune system. Because psoriasis is an autoimmune response, this effect could help treat the condition internally. Topical oils and ointments for psoriasis containing vitamin D can also help treat flare-ups. Vitamin D can slow the growth of new cells, so vitamin D oil applied directly to the flare can help thin the plaque.

Back of body Psoriasis
Psoriasis plaques can consist of a few spots of dandruff-like scales or major eruptions that cover large areas. While the disease can affect any part of your body, it most often surfaces on the scalp, elbows, knees, back, face, palms, and feet. Steroid creams or ointments (topical corticosteroids) are commonly used to treat mild to moderate psoriasis in most body areas, including the back. The treatment works by reducing inflammation, slowing the production of skin cells and relieving itching. A coal tar bath is a common treatment – coal tar is also available in lotions, creams, foams and shampoos.

A picture containing person, tattoo, indoor, pink Description automatically generated
Picture Credit: Psoriasis of the Back.
Attribution: Psoriasis_on_back.jpg: User: The Wednesday Island (of the English Wikipedia) derivative work: James Heilman, MD, CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/&gt;, via Wikimedia Commons
File URL: https://upload.wikimedia.org/wikipedia/commons/f/f5/Psoriasis_on_back1.jpg

Psoriatic Arthritis
In up to about a third of people with psoriasis, the inflammation from psoriasis causes arthritis. Symptoms of psoriatic arthritis include joint swelling, stiffness and pain. You should see your doctor or specialist if you have any of the symptoms associated with psoriatic arthritis. Early treatment can reduce damage to your joints.[30] Psoriatic arthritis is similar to rheumatoid arthritis (RA) in symptoms and joint swelling (inflammation). But it tends to affect fewer joints than RA, and it does not make the typical RA antibodies. The arthritis of psoriatic arthritis comes in five forms[31]:

  • Arthritis that affects the small joints in the fingers, toes, or both.
  • Asymmetrical arthritis of the joints in the hands and feet.
  • Symmetrical polyarthritis, which is similar to RA.
  • Arthritis mutilans, a rare type of arthritis that destroys and deforms joints.
  • Psoriatic spondylitis, arthritis of the lower back (sacroiliac sac) and the spine.

Nail Psoriasis[32]
Psoriasis can affect different organs and tissues throughout the body, including the nails and the joints.

Nail psoriasis (aka Psoriatic onychodystrophy or psoriatic nails) is a type of psoriasis that causes visible changes to the nails. Nail psoriasis causes various symptoms on the fingernails and toenails, such as nail separation, discolouration, or crumbling nails. Sometimes, doctors use a scoring system to determine the severity of psoriasis. The results may help doctors recommend suitable treatments, including topical creams, corticosteroid injections, or oral medications. The MedicalNewsToday article[33] looks at nail psoriasis in more detail, including the possible symptoms, the scoring systems that doctors may use to diagnose the condition, and the treatment options.

word-image-3251-5
Photograph showing the effects of psoriasis on the toenails
File URL: https://upload.wikimedia.org/wikipedia/commons/4/4c/NailPsoriasis.JPG

Attribution: JVO27, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0&gt;, via Wikimedia Commons

Statistics vary, but according to the National Psoriasis Foundation, about 50% of people with psoriasis have psoriasis on their nails, while close to 90% of people with psoriasis will have nail psoriasis at some point during their life. Learn more about nail psoriasis at: https://www.medicalnewstoday.com/articles/314542

Treatments
Treatment for nail psoriasis may take time because the nails grow slowly. The American Academy of Dermatology Association (AAD) suggests that it may take six months or more to clear certain symptoms, such as a build-up of debris under the nail. People may need to apply topical treatments one or two times a day for several months to treat nail psoriasis. A doctor may sometimes create a treatment plan that includes a combination of treatment options. One type may be topical treatments, which are those that people apply directly to the nails. Examples include:

  • Corticosteroids: Strong corticosteroids can be effective for most symptoms of nail psoriasis. People may need to use corticosteroids one or two times a day for up to nine months.
  • Calcipotriene: Calcipotriene (Dovonex) may be as effective as corticosteroids for treating build-up underneath the nail.
  • Tazarotene: Topical tazarotene (Tazorac) may be particularly effective for treating separation of the nail, pitting, and discolouration.

When topical treatments are ineffective, people may require specialist medical treatment. The treatment options may include:

  • Corticosteroid injections: A doctor will inject corticosteroids into or around the nail. Corticosteroid injections can help treat nail separation, ridges, build-up under the nail, and thickening. People may require repeat injections.
  • Lasers: Laser treatment targets the area of psoriasis with an intense beam of light.
  • Psoralen and UVA light (PUVA): PUVA is a treatment that may help treat nail discolouration and separation. People take a medication called psoralen orally or apply it topically to the nails and then expose the affected area to UVA rays.

For severe cases of nail psoriasis, people may need to take an oral medication that works throughout the body to treat psoriasis. These medications include:

  • methotrexate
  • retinoid
  • biologics
  • cyclosporine
  • apremilast

Psoriasis Complications in Severe Cases[34]
The following complications may be noted in severe cases of psoriasis:

  • Eye conditions: Such as conjunctivitis, blepharitis and uveitis, as well as red eyes, blurry vision, asymmetrical pupils, teary eyes and sensitivity to light.
  • Psoriatic arthritis, which causes pain, stiffness, and swelling in and around the joints.
  • Obesity: People with severe psoriasis tend to be obese.
  • Temporary skin colour changes (post-inflammatory hypopigmentation or hyperpigmentation) where plaques have healed.
  • Type 2 diabetes.
  • Cardiovascular diseases such as irregular heartbeat and atherosclerosis.
  • Limitations of activities, including those requiring skin exposure (such as swimming, sauna and Turkish bath) and work situations.
  • Metabolic syndrome: a cluster of conditions that affect metabolism and cardiovascular health, including high blood pressure, high cholesterol, and high insulin levels. Psoriasis may increase your risk of metabolic syndrome and, in turn, increase your risk of heart disease.
  • Autoimmune diseases such as celiac disease, sclerosis and the inflammatory bowel disease called Crohn’s disease.
  • Parkinson’s disease due to the detrimental effect of chronic inflammation on the neuronal tissue.
  • Kidney disease.
  • Mental health conditions such as low self-esteem and depression, relationship difficulties, negative body image, feelings of shame, guilt, embarrassment, and fear of being considered dirty or infectious.
  • Hearing Loss: Even if psoriasis doesn’t affect the skin in and around your ears, psoriasis itself may make you more likely to get a mild form of hearing loss called sudden sensorineural hearing loss (SSNHL)[35].

Just because you have psoriasis, it doesn’t mean you’ll automatically develop any of the above complications. At times, treatment can lead to clear skin and no psoriasis symptoms. The medical term for this is “remission.” A remission can last for months or years; however, most last from 1 to 12 months. Psoriasis is notoriously unpredictable, so it’s impossible to know who will have a remission and how long it will last. Even when psoriasis clears, it’s likely to return. When it does, treatment can help control it so that your psoriasis doesn’t worsen.[36]

History of Psoriasis[37]
A brief history of psoriasis excerpted from various sources is as follows:

Some scholars believe psoriasis to have been included among various skin conditions called tzaraath[38] (translated as leprosy) in the Hebrew Bible, a skin condition imposed as a punishment for slander. A person was deemed as “impure” (see tumah and taharah) during their afflicted phase and is ultimately treated by the kohen[39]. However, it is more likely that this confusion arose from using the same Greek term for both conditions. The Greeks used the term lepra for scaly skin conditions. They used the term psora to describe itchy skin conditions.  It became known as Willan’s lepra in the late 18th century when English dermatologists Robert Willan and Thomas Bateman differentiated it from other skin diseases. Leprosy, they said, is distinguished by the regular, circular form of patches, while psoriasis is always irregular. Willan identified two categories: ‘leprosa graecorum’ and ‘psora leprosa’.[40]

Psoriasis is thought to have first been described as such in Ancient Rome by Cornelius Celsus[41]. Celsus (circa 25 to 50 AD) was a Roman encyclopaedist known for his medical work, De Medicina, which is believed to be the only surviving section of a much larger encyclopaedia. ‘The De Medicina is a primary source on diet, pharmacy, surgery and related fields, and it is one of the best sources concerning medical knowledge in the Roman world. The British dermatologist Thomas Bateman described a possible link between psoriasis and arthritic symptoms in 1813.

The history of psoriasis is littered with treatments of high toxicity and very doubtful effectiveness. In the 18th and 19th centuries, Fowler’s solution, which contains a poisonous and carcinogenic arsenic 
compound, was used by dermatologists in treating psoriasis,[42] as was mercury, sulphur, iodine, and phenol when it was incorrectly believed that psoriasis was an infectious disease. Coal tars were widely used with ultraviolet light irradiation as a topical treatment approach in the early 1900s.[43] At the same time, psoriatic arthritis cases were treated with intravenously-administered gold preparations in the same manner as rheumatoid arthritis.

While it may have been visually, and later semantically, confused with leprosy, it was not until 1841 that the condition was finally given the name psoriasis by the Viennese dermatologist Ferdinand von Hebra. The name is derived from the Greek word psora which means to itch.[44] In the 1800s, von Hebra was the first to use modern research techniques to study skin conditions. He also removed “lepra” from the description of psoriasis.

During this century, French doctors discovered the connection between psoriasis and a form of arthritis called psoriatic arthritis. Other medical professionals of the time continued to make discoveries that led to later research sub-categorizing psoriasis. For example, Australian dermatologist William J. Munro discovered mico-abscesses in the top layer of the skin in people with the condition. Later research would find that these abscesses are part of psoriasis vulgaris, a common form of this condition.

Heinrich Köbner, a German-Jewish dermatologist, studied medicine in Berlin, earning his doctorate in 1859 at Breslau. Afterwards, he performed hospital duties in Vienna under von Hebra and in Paris with Alfred Hardy. He made an important discovery during the 19th century. He found that people with psoriasis may also develop psoriatic lesions in previously unaffected areas that have experienced trauma, such as a cut, burn, or bruise. Doctors still use the Köbner phenomenon as a diagnostic tool today.

During the 20th century, psoriasis was further differentiated into specific types with advancements in classifying psoriasis and its symptoms. In 1910, Leo von Zumbusch was the first to describe pustular psoriasis, a rare form of psoriasis that causes pustules, blisters, fever, and fatigue.

In 1926, a Dr Woronoff discovered that people with psoriasis might have a pale ring of skin around healing lesions. This halo, or ‘Woronoff ring’, is another diagnostic tool that medical professionals use. The appearance of a Woronoff ring may be a sign that psoriasis lesions are healing.

In 1963, E. J. Van Scott found that people with psoriasis have a rapid turnover of cells, which is a marker of an autoimmune condition. The discovery that psoriasis is an autoimmune condition affected the way doctors treated this condition.

Confusion of Psoriasis with Eczema
Psoriasis is often confused with another skin condition – eczema. The following table[46] compares the conditions:

Psoriasis and Eczema table
[1] Source: https://www.medicalnewstoday.com/articles/315749#eczema-treatment

Is there a Link between Asthma and Eczema?
Several studies indicate a link between eczema and asthma – if one or both parents has eczema, asthma, or seasonal allergies, their child is more likely to have eczema. What’s more, children with the disease may be more at risk for getting allergies or asthma. Scientists are still studying the link between the conditions. Asthma and eczema are both linked to inflammation. If you have one condition, research suggests you may be more likely than most people to have the other. Not everyone with asthma has eczema, but there’s a strong link between having eczema as a child and developing asthma later on in life.[47]

People with asthma have swollen (inflamed) and “sensitive” airways that become narrow and clogged with sticky mucus in response to certain triggers.

Researchers in the US have discovered that[48]:

  • 35% of adults with asthma or allergic rhinitis (nasal allergies) had eczema as a child.
  • Similarly, up to 80% of children with eczema grow up to develop asthma or allergic rhinitis.
  • 1 in 3 infants born to moms with asthma will develop eczema.
  • 15-20% of children have a diagnosis of eczema.
  • 1-2% of adults have a diagnosis of eczema.
  • 60% of eczema patients are diagnosed in the first year of life.
  • 90% of eczema patients are diagnosed by the time they are five years old.
  • Eczema usually resolves by adulthood. But 10-30% of people continue to have symptoms.
  • For people living with eczema, 91% experience itching as the most common symptom.
  • Children with eczema and allergies in infancy were seven times more likely to develop asthma by the age of three. They were 12 times more likely to develop allergic rhinitis (nasal allergies). They also have an elevated risk of developing food allergies than those without eczema and allergies.
  • When both parents have eczema, their children have a 70% chance of developing it.

Updated Information from MedicalNewsToday[49]
Topical treatment is usually the first weapon prescribed, but if psoriasis does not improve, doctors may prescribe oral medication or injections that work throughout the body. There are two types of systemic medicines available:

  • biological medications, which contain living immune system cells; and
  • non-biological medications, which contain synthetic ingredients.

The following information offers an overview of the medications included in this update.

Psoriasis table 2

The MedicalNewsToday update says that there are many biological and non-biological medications for psoriasis that come in different forms and strengths. Details of five non-biological medications are provided (Methotrexate, Cyclosporine, Acitretin. Apremilast and Dimethyl fumarate) are provided. Details of four biological medications for psoriasis (Etanercept, Adalimumab, Infliximab and Ustekinumab) are also provided.

The following medications are other biological injections:

Doctors prescribe these medications for moderate to severe psoriasis that has not responded to other treatments.

 Sources and Further Reading

Caution: No advice is implied or given in articles published by us. This guide is for general interest only and is compiled from the sources stated but has not been medically reviewed. It should never be used as a substitute for obtaining advice from your Doctor, a consultant Dermatologist (or Rheumatologist for artritic psoriasis) or other qualified clinician/medical practitioner. If you have already been given dietary advice you should not make changes without first talking to your GP, consultant or dietitian. The medications mentioned include names for US drugs. The facts are believed to be correct as at the date of publication, but there may be certain errors and omissions for which we cannot be responsible. The information contained in this paper is provided for informational purposes only. There is no implied endorsement or promotion of any organisation by the writer. The hyperlinks were valid at the date of publication.

  1. Source: https://www.theparkerclinic.com/medical-dermatology-procedures-cleveland/psoriasis/
  2. T cells are major components of the adaptive immune system. Their roles include directly killing infected host cells, activating other immune cells, producing cytokines and regulating the immune response. Source: https://teachmephysiology.com/immune-system/cells-immune-system/t-cells/
  3. Guttate psoriasis is typically associated with a bacteria or virus that triggers symptoms one to three weeks after infection. The lesions are characteristically small (1 to 10 millimetres in diameter), pink, tear-shaped, and covered with fine scales. Source: https://www.verywellhealth.com/types-of-psoriasis-1069495
  4. Strep throat is a bacterial infection that can make your throat feel sore and scratchy. If untreated, strep throat can cause complications, such as kidney inflammation or rheumatic fever. Source: https://www.mayoclinic.org/diseases-conditions/strep-throat/symptoms-causes/syc-20350338
  5. Summarised at: https://psychology.fandom.com/wiki/Psoriasis
  6. Source: https://www.nhs.uk/conditions/psoriasis/ © Crown Copyright is acknowledged
  7. Source: Boehncke WH, Schön MP (September 2015). “Psoriasis”. Lancet. 386 (9997): 983–94. doi:10.1016/S0140-6736(14)61909-7. PMID 26025581. S2CID 208793879.
  8. Source: Questions and Answers About Psoriasis”. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017.
  9. Source: Parisi R, Symmons DP, Griffiths CE, Ashcroft DM (February 2013). Identification and Management of Psoriasis and Associated ComorbidiTy (IMPACT) project team. “Global epidemiology of psoriasis: a systematic review of incidence and prevalence”. The Journal of Investigative Dermatology. 133 (2): 377–85. doi:10.1038/jid.2012.339. PMID 23014338.
  10. Source: “Questions and Answers About Psoriasis”. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 12 April 2017.
  11. Source: Menter A, Gottlieb A, Feldman SR, Van Voorhees AS, Leonardi CL, Gordon KB, et al. (May 2008). “Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics”. Journal of the American Academy of Dermatology. 58 (5): 826–50. doi:10.1016/j.jaad.2008.02.039. PMID 18423260.
  12. Source: Boehncke WH, Schön MP (September 2015). “Psoriasis”. Lancet. 386 (9997): 983–94. doi:10.1016/S0140-6736(14)61909-7. PMID 26025581. S2CID 208793879.
  13. Ibid
  14. Source: Jain S (2012). Dermatology : illustrated study guide and comprehensive board review. Springer. pp. 83–87. ISBN 978-1-4419-0524-6.
  15. Source: “Psoriatic Arthritis”. The Johns Hopkins University School of Medicine and the Johns Hopkins Arthritis Center.
  16. Source: Who’s At Risk, Be Joint Smart (a coalition of the National Psoriasis Foundation and the Arthritis Foundation).
  17. Source: Ritchlin, CT; Colbert, RA; Gladman, DD (March 2017). “Psoriatic Arthritis”. New England Journal of Medicine (Review). 376 (10): 957–70. doi:10.1056/NEJMra1505557PMID 28273019S2CID 43867408
  18. Source: “Psoriatic Arthritis”. WebMD LLC.
  19. Ibid
  20. Source: Ritchlin, CT; Colbert, RA; Gladman, DD (March 2017). “Psoriatic Arthritis”. New England Journal of Medicine (Review). 376 (10): 957–70. doi:10.1056/NEJMra1505557PMID 28273019S2CID 43867408
  21. Source: https://www.nhs.uk/conditions/psoriasis/treatment/
  22. Source: https://my.clevelandclinic.org/health/diseases/6866-psoriasis
  23. Source: https://www.medicalnewstoday.com/articles/is-salt-water-good-for-your-skin
  24. Source: https://www.psoriasis.org/phototherapy/
  25. References/Sources: Various, including https://www.webmd.com/skin-problems-and-treatments/psoriasis/scalp-psoriasis, https://www.headandshoulders.co.uk/en-gb/all-articles/scalp-conditions/how-to-treat-scalp-psoriasis/, https://www.nioxin.com/en-GB/caring-for-your-hair/scalp-care/scalp-psoriasis-hair-loss and https://www.nhs.uk/conditions/psoriasis/symptoms/
  26. Source: https://www.webmd.com/skin-problems-and-treatments/psoriasis/scalp-psoriasis
  27. Source: https://www.webmd.com/skin-problems-and-treatments/psoriasis/scalp-psoriasis-treatment
  28. Source: https://www.healthline.com/health/psoriasis/vitamin-d-for-psoriasis
  29. See: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130965/
  30. Source: https://my.clevelandclinic.org/health/diseases/6866-psoriasis
  31. Source: https://www.hopkinsmedicine.org/health/conditions-and-diseases/arthritis/psoriatic-arthritis
  32. Source: https://www.medicalnewstoday.com/articles/nail-psoriasis-severity-index#summary
  33. Ibid
  34. Sources: various, including https://www.mayoclinic.org/diseases-conditions/psoriasis/symptoms-causes/syc-20355840, https://www.healthline.com/health/psoriasis/complications-psa-anxiety, https://www.everydayhealth.com/psoriasis/guide/symptoms/#9-ways-to-relieve-psoriatic-foot-symptoms, https://www.twssc.org/blog/complications-of-psoriasis, https://cks.nice.org.uk/topics/psoriasis/background-information/complications/ and https://www.webmd.com/skin-problems-and-treatments/psoriasis/psoriasis-in-ears
  35. One study found that people with psoriasis were 50% more likely to be diagnosed with SSNHL. Source: https://www.webmd.com/skin-problems-and-treatments/psoriasis/psoriasis-in-ears
  36. Source: American Academy of Dermatology Association, at: https://www.aad.org/public/diseases/psoriasis/treatment/medications/how-long
  37. Sources: https://en.wikipedia.org/wiki/Psoriasis#cite_note-120, https://www.medicalnewstoday.com/articles/history-of-psoriasis-2#20th-century, https://en.wikipedia.org/wiki/Psoriasis
  38. See explanation at: https://en.wikipedia.org/wiki/Tzaraath, https://en.wikipedia.org/wiki/Psoriasis#cite_note-120,
  39. Source: Gruber F, Kastelan M, Brajac I (2004). “Psoriasis treatment–yesterday, today, and tomorrow”. Acta Dermatovenerologica Croatica. 12 (1): 30–4. PMID 15072746
  40. Source: Meenan FO (March 1955). “A note on the history of psoriasis”. Irish Journal of Medical Science. 30 (351): 141–2. doi:10.1007/bf02949688. PMID 14353580. S2CID 27467338.
  41. Source: Benedek TG (June 2013). “Psoriasis and psoriatic arthropathy, historical aspects: part I”. Journal of Clinical Rheumatology. 19 (4): 193–8. doi:10.1097/RHU.0b013e318293eaeb. PMID 23669809. S2CID 5813486.
  42. Source: Gruber F, Kastelan M, Brajac I (2004). “Psoriasis treatment–yesterday, today, and tomorrow”. Acta Dermatovenerologica Croatica. 12 (1): 30–4. PMID 15072746
  43. See: Benedek TG (August 2013). “Psoriasis and psoriatic arthropathy: historical aspects: part II”. Journal of Clinical Rheumatology. 19 (5): 267–71. doi:10.1097/RHU.0b013e31829d4ad4. PMID 23872545. S2CID 199596315.
  44. Source: Glickman FS. Lepra, psora, psoriasis. J Am Acad Dermatol. 1986 May;14 (5 Pt 1): 863-6. PMID 3519699
  45. Source: https://www.medicalnewstoday.com/articles/315749#eczema-treatment
  46. Sources: https://www.pennmedicine.org/updates/blogs/health-and-wellness/2022/march/psoriasis, https://www.harveywatersofteners.co.uk/blog/the-difference-between-eczema-and-psoriasis/, https://www.webmd.com/skin-problems-and-treatments/psoriasis/psoriasis-or-eczema and https://www.nhs.uk/conditions/atopic-eczema/ Table © Copyright Martin Pollins
  47. Sources: https://www.healthline.com/health/severe-asthma/asthma-and-eczema, https://www.webmd.com/skin-problems-and-treatments/eczema/eczema-allergies-link#1,
  48. Source: https://asthma.net/living/eczema-link
  49. Source: https://www.medicalnewstoday.com/articles/best-medications-for-psoriasis-types-and-other-treatments#outlook, received 9th August 2022.

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