“Psoriasis is affecting millions globally, influencing not only skin health but also joints, overall immunity, and mental well-being,” says Dr. Prachi B Bodkhe, dermatologist at Envi Aesthetics. “Though a cure can’t be promised, this condition can be effectively managed with medical supervision, lifestyle changes, and awareness of associated conditions,” she adds.
It is important that patients avoid self-medication. As Bodkhe explains, “Psoriasis management is complex, and treatments that work for one person may be harmful or ineffective for another.” Following your care provider’s guidance, undergoing tests when recommended, and adopting a healthy lifestyle can help reduce recurrence and prolong remission. This World Psoriasis Month, dermatologists delve into early signs to watch out for, and how to aid management of this incurable condition.
Early signs and diagnosis
Dr Akanksha Sanghvi, dermatologist and founder of Oprava Aesthetics, shares her expertise on the common signs of psoriasis and how it is diagnosed.
“Psoriasis most often begins subtly like a salmon pink patch commonly seen on knees and elbows or scalp as well. Initially, it may be slightly rough to touch with fine flakes and can have a mild burning sensation. It progresses to get thicker over time with silvery scales,” says Sanghvi.
Distinguishing psoriasis from eczema can be tricky. “The most important symptom distinguishing eczema from psoriasis is itching. Eczema tends to present with intense itching as compared to psoriasis. The location of the rash is also a key differentiator, psoriasis tends to occur on scalp, knees and elbows and lower back. Eczema is commonly noted in behind knees, inside elbow folds and nape of the neck, especially in children,” she explains.
Key diagnostic criteria
Dermatologists use several tools and examinations to confirm a psoriasis diagnosis.
1. Clinical examination: Doctors look for specific signs, such as the ‘Koebner`s Phenomena’ (lesions occurring in areas of trauma), symmetrical distribution, well-defined borders, and silvery scales. When these scales are gently removed, they reveal underlying bleeding pinpoints—a sign known as ‘Auspitz Sign’.
2. Nail changes: Psoriasis can cause tiny dents or pits on the nail surface, thickening, discoloration, or the nail lifting away from the skin.
3. Psoriatic arthritis: In some people, the condition affects the joints, causing pain, stiffness, and swelling, particularly in the fingers, toes, or lower back.
4. Dermatoscopy: A hand-held skin microscope called a dermatoscope can reveal typical patterns in certain skin diseases. Psoriasis shows regular tiny red dots and white scales, while eczema and fungal infections have different patterns.
5. Skin biopsy: A small piece of skin is taken for an examination and looked at under a microscope. On biopsy, psoriasis shows thickened skin layers, with a thinner or missing upper layer and tiny collections of white blood cells called microabscesses.
Managing symptoms: From itching to joint pain
Patients can effectively manage the specific and often debilitating symptoms of psoriasis, such as severe itching, scaling, and joint pain associated with psoriatic arthritis.
Bodkhe notes that managing symptoms involves both short-term relief during flares and long-term strategies to minimise recurrence. “All the mentioned symptoms require medical treatments like High-potency topical corticosteroids or calcineurin inhibitors to reduce inflammation. What I expect my patients to do is, use fragrance-free ceramide-based moisturisers as much as required. Ceramide containing moisturisers have healing properties, they repair the barrier and protect your skin from external factors which aggravate itch and also to a certain extent reduce the scaling,” she explains. For joint pain, she recommends considering physiotherapy along with prescribed medications.
Other treatments include:
1. Keratolytic agents like urea and salicylic acid, which help to loosen scales.
2. Narrowband UVB phototherapy, which helps to slow skin turnover.
Lifestyle changes
“Lifestyle measures cannot replace medical treatment, but they can significantly reduce flare-ups and improve quality of life,” says Bodkhe.
She highlights several key lifestyle changes:
1. Diet: Include anti-inflammatory foods like leafy greens, berries, fatty fish, nuts, and whole grains. Reduce packed and processed foods, sugar, and alcohol.
2. Weight management: Maintain a healthy weight, as obesity is linked to more severe disease and poorer treatment response.
3. Stress management: Use mindfulness, yoga, or breathing exercises to lower stress hormones. Cognitive-behavioural therapy can also help with coping with chronic illness stress, and regular physical activity can boost mood.
Categories of psoriasis
Sanghvi outlines the different types of psoriasis and their treatment approaches.
1. Plaque psoriasis: The most common type, it presents as thick, salmon pink plaques with silvery scales.
2. Guttate psoriasis: Small, red, scaly spots often appearing after a strep throat infection.
3. Inverse psoriasis: Smooth, red patches in skin folds with less scaling.
4. Pustular psoriasis: White or yellow pus-filled bumps on red skin, not caused by infection.
5. Erythrodermic psoriasis: A rare, severe type where most of the skin becomes red, hot, itchy, and peels. This requires urgent medical attention.
Understanding palmo-plantar psoriasis
The diagnosis and clinical presentation of palmo-plantar psoriasis differ from other forms of psoriasis. Palmo-plantar psoriasis presents as thick, scaly plaques on the palms and/or soles, often with painful cracks. “Unlike other forms of psoriasis, these lesions cause major functional limitations, making walking, working, or handling objects painful. They are also often resistant to standard topical treatments because of the thickened skin layer,” Bodhke explains.
The condition may be mistaken for eczema, fungal infections, or contact dermatitis, sometimes requiring a biopsy for confirmation. “The difficulty in treatment arises from the combination of thick skin, constant mechanical stress, and the need for strong but safe medications,” she outlines.
Due to reduced topical penetration in PPP, treatment often needs to be more intensive and multi-pronged. Bodkhe lists effective treatment options:
1. High-potency corticosteroids under occlusion for better absorption.
2. Combination treatments with topical calcipotriol.
3. Targeted phototherapy like PUVA or excimer laser.
4. Systemic therapy with immunosuppressants, immunomoderators, and biologics like Tofacitinib and adalimumab for severe cases or when there is psoriatic arthritis.
5. Smoking cessation and limiting alcohol consumption are also a must.
Psoriasis and associated conditions
There is a known link between psoriasis and other autoimmune conditions. Bodkhe explains the specific connection between palmo-plantar psoriasis and thyroid dysfunction. “Yes, there are a few studies showing links between Palmo-plantar psoriasis (PPP) and autoimmune thyroid conditions, particularly Hashimoto’s thyroiditis, however not all patients diagnosed with palmo-plantar psoriasis have Thyroid related illness,” she states.
Possible reasons for this link are shared autoimmune mechanisms, where the immune system attacks healthy tissues, and chronic systemic inflammation, which increases the risk of multiple autoimmune conditions.
“The awareness matters as early detection and treatment of thyroid disease may help stabilize skin symptoms,” says Bodkhe. She advises that clinicians should screen PPP patients for thyroid problems when symptoms suggestive of thyroid disease are present.
Treatment
Treatment for psoriasis depends on its type and severity. “The aim is always to calm the overactive immune system, reduce inflammation, and heal the skin,” Sanghvi says.
1. Topical treatments: For plaque psoriasis, doctors often start with corticosteroid creams, vitamin D-based creams, and emollients.
2. Phototherapy: For larger areas or when creams aren`t enough, controlled UVB light can slow skin cell growth.
3. Systemic medicines: Oral medications like methotrexate, cyclosporine, or acitretin can control inflammation from within.
4. Biologics: These targeted injections block specific immune signals and are used for moderate-to-severe cases or when other treatments fail.
5. Type-specific treatments: Guttate psoriasis may clear with moisturisers, light therapy, or antibiotics. Inverse psoriasis responds to mild steroid creams. Pustular and erythrodermic psoriasis are more serious and often require hospitalization with strong oral or injected medicines.
Across all types, Sanghvi emphasises, “Avoiding triggers, keeping skin well moisturised, and following a dermatologist’s plan are key to long-term control.”