A Different Drum
Malaya Pimentel-Santos, MD
“For many reasons, psoriasis can be psychologically devastating. Patients’ lives become especially difficult when psoriasis is present in highly visible areas of the skin such as the face and hands. Related psychological problems can affect every day social activities and work. It causes embarrassment, lack of self-esteem, anxiety and increased prevalence of depression” – WHO Global Report on Psoriasis 2016
PSORIASIS is a chronic (long-standing and often lifelong), non-communicable, inflammatory disorder that primarily affects the skin, but also causes changes in the nails, as well as the joints. Most patients are in the adult age group, and the psoriasis global prevalence is placed at around 2-3 percent (with some studies reporting a prevalence of as high as 11 percent). It is estimated that over 125 million people worldwide are currently living with psoriasis.
The most characteristic feature of psoriasis is the development of raised, red, scaly, itchy, irritated, even painful skin lesions (plaques). Although uncommon, it may sometimes affect the entire skin surface, a potentially life-threatening condition known as psoriatic erythroderma. About one in 10 persons with psoriasis also suffers from arthritis of the hands, feet, neck, and back. This may lead to joint deformity and physical disability.
Numerous studies have documented the profound negative impact that psoriasis can have on the quality of life of affected individuals. It also places an undue socioeconomic burden, because of the high cost of treatments as well as the lost opportunities for employment and productivity.
In addition, a significant proportion of persons with psoriasis also suffer from associated diseases (‘co-morbidities’) such as diabetes, cardiovascular disease, and depression.
Causes of psoriasis
Once believed to be contagious, psoriasis is now known to be a complex, multifactorial, although definitely non-communicable disease. Several risk factors and triggers have been identified, including genetics, infections, medications, stress, hormones, and weather. Skin injury also contributes to the development of new lesions, an occurrence known as the “Koebner phenomenon”.
A key element in psoriasis is the presence of an immune-related disturbance in the maturation of the cells in the skin. Normally a tightly regulated process, skin cell proliferation in psoriasis occurs at a much faster rate than usual, causing cells to accumulate on the skin surface and resulting in characteristic symptoms such as thickened, red, scaly lesions. Recent studies have identified a specific protein, interleukin-17A (IL-17A) that plays a central role in this immune disregulation.
Treatment, but not cure
There is – as yet – no permanent cure for psoriasis, and treatment is directed towards the control of symptoms. Therapeutic options include a broad range of topical, oral, and injectable medications. There are also physical treatments such as phototherapy (ultraviolet or UV light treatments) and medicated baths. More recently, we have witnessed the development of a promising new class of agents: the biologic drugs.
One novel drug in this class is secukinumab, which selectively inhibits IL-17A and diminishes the abnormal immune response that is present in psoriasis. Clinical trials have demonstrated its effect on reducing disease symptoms for both plaque psoriasis and psoriatic arthritis. It is now recommended for use in adults with moderate to severe psoriasis.
Caring for the person, beyond the skin disease
The 2016 World Health Organization (WHO) Global Report on Psoriasis highlights the public health impact of psoriasis, placing it on the health agenda as a serious, non-communicable disease with immense physical, economic and psychosocial effects on patients.
The report also emphasizes the importance of raising awareness among health providers as well as the general public, thereby reducing the deep-seated stigma that has long been associated with psoriasis. Even beyond treating the symptoms, the aim is to diminish the psychosocial costs of psoriasis, create better support for affected individuals, and broaden access to quality health care and effective treatment.
Vital Signs Issue 88 Vol. 4, June 1-30 2016