DR. SUPREET SINGHPsoriasis, a chronic inflammatory skin disease, usually immune mediated is often triggered by intake of certain drugs, season changes, lifestyle changes, stress, trauma of anykind, diseases like Diabetes Mellitus, obesity and so on. Psoriasis is known to affect 1-2 per cent of the world population. The disease is known for its wide geographical variations due to racial; geographical and environmental reasons. The prevalence figures from various studies from North India range from 0.8-5.6 per cent. The disease is more common in Kashmir region (5 per cent approx) than Jammu region(2-3 per cent approx). Although not a life-threatening condition under ordinary circumstances, psoriasis can have a significant negative impact on the psychological setup of the patient. The social, economic and financial implications of disease are often underestimated by healthcare professionals, government as well as general public. This might be due to the fact that our society assigns more value to the physical sequelae of a disorder and a disease which does not grossly impair a person’s capability to live a healthy life and is not per-se lethal, does not entice much sympathy.The spectrum of psoriasis ranges from mild disease with a few plaques and minimal itching to severely incapacitating psoriatic arthritis and patients having skin failure secondary to erythroderma (involvement of almost whole body). The level of impact on daily activities is directly correlated with the severity of itching, pain, location and extent of lesions. Lesions which are extensive and located on socially visible sites like face, hands, etc. are more likely to cause cosmetic concerns amongst patients resulting in problems like anxiety, depression, low self-esteem and in severe cases may kindle suicidal tendencies.For this problem people often seek advice from healthcare professionals like General Physicians, Homeopathy, and Dermatologists. Some get indulged in indigenous medication and often fall prey to quackery especially in Jammu region.The treatment often depends on the severity of disease, Dermatology life quality index, comorbidities like Diabetes, Obesity etc. Some times the patient needs to be admitted and treated with some high-end medicines like Methotrexate, Acitretin, Cyclosporine, Biologic agents. Before them dermatologist may order certain investigations like CBC, renal and liver function tests. Rheumatoid factor, ESR may be elevated in erythrodermic and pustular psoriasis, Uric acid levels are high in psoriasis. If only hand and feet are involved, obtain scrappings for fungal studies, Pregnancy test, Hepatitis serology, PPD.Psoriasis Area Severity Index (PASI) is the most widely used measurement tool which assesses the severity of the condition and allows to evaluate the treatment efficiency. Topical therapy is used in mild to moderate psoriasis. Emollients and moisturisers may help in improving barrier function and retain the hydration of stratum corneum. Topical agents used are coal tar, dithranol, corticosteroids, vitamin D analog, and retinoids.The drug of choice is methotrexate and should be used as long as it remains effectiveCyclosporine can be used to induce a clinical response but its use should be intermittent.When patients fail to respond to methotrexate, switch to biological agents; in some cases combine with methotrexate.Systemic drugs are used in extensive cases, the involvement of nails and psoriatic arthritis. Methotrexate, retinoids, cyclosporine, and fumarates are possible options. Routine blood, liver functions, and renal functions should be monitored in patients on systemic therapy.Biologicals are manufactured proteins that interrupt the immune process in psoriasis which are infliximab, adalimumab, etanercept, and interleukin antagonists. Before starting any biological agent, the patient should be worked up for tuberculosis and hepatitis. There is a serious risk of infections in these patients and all precautions should be taken that the patient is not severely immunocompromised.Prolonged use of steroids and other immunosuppressives may delay wound healing.Ocular psoriasis requires aggressive treatment with topical corticosteroids.Patients with psoriasis should avoid all skin trauma for fear of inducing Kobner reaction. In addition, psoriatic patients should avoid the use of beta-blockers, chloroquine or NSAIDs. They should also avoid alcohol because of risk of developing fatty liver.Psoriasis may be a skin disorder but its management is very complex and usually requires a team of professionals dedicated to this disease. Besides the dermatologist, the nephrologist, plastic surgeon, pharmacist, rheumatologist, and an ophthalmologist should manage these patients. The key goal is to improve the quality of life by educating the patient about avoiding triggers. The pharmacist should educate the patient on the use of moisturizers and managing dry skin. Further compliance with medications is vital; plus the pharmacist should ensure that the patient is on no medications that can cause flare-ups. The nurse should educate the patient on changes in lifestyle by avoiding alcohol, smoking, stress and dry cold weather. While the sun is beneficial, too much should be avoided. The nurse should monitor the patient for self-harm and refer the patient to a mental health counselor. Finally, the patient should be told to eat healthily, exercise regularly and maintain a healthy weight. All patients with psoriasis need lifelong follow up because relapses are common. An interprofessional team approach to management will yield improved outcomes.Even though psoriasis is a benign skin disorder, it is a lifelong illness with no cure. Everyone undergoes remissions and relapses and overall it leads to poor quality of life. Today there are several reports indicating that psoriasis also increases risk of adverse cardiac events. Psoriasis also is associated with alcoholism, smoking, depression, risk of lymphoma, suicide, adverse drug reactions and several types of skin cancers. Evidence continues to mount that psoriasis is associated with hypertension, renal and heart disease. Overall, patients with psoriasis involving the palms and soles tend to have a much poorer quality of life than those who have psoriasis on other parts of the body.As psoriasis is a chronic immune-mediated condition, some people may take immunosuppressant drugs to keep their symptoms under control. These medications can reduce immune function, which may increase the risk of infection with SARS-CoV-2 or other infectious agents. Immunosuppressive drugs could also increase the risk of severe symptoms.According to the Centers for Disease Control and Prevention (CDC), conditions or medications that weaken the immune system and cause people to become immunocompromised increase risk of severe COVID-19.The International Psoriasis Council (IPC) recommend that people with psoriasis who receive a COVID-19 diagnosis discuss discontinuing or postponing their use of immunosuppressant medications with their doctor. However, the IPC caution that doctors should carefully weigh the benefit-to-risk ratio of immunosuppressive treatments on an individual basis.The medical board of the NPF do not recommend that people with psoriasis stop their treatment unless they have an active infection. They suggest that those in high risk groups discuss options with their doctor.The CDC list the following as high risk:those aged 65 years and older, people living in a nursing home or care facility, smokers, individuals with underlying medical conditions (especially if poorly controlled) or risk factors that include: chronic lung disease, moderate or severe asthma,serious heart conditions,a weakened immune system, for instance, due to cancer treatment or HIV,severe obesity,diabetes,chronic kidney disease, liver disease.The writer is Department of Dermatology SMGS Hospital, Jammu.
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