Psoriasis
What is Psoriasis?
Psoriasis is an autoimmune disease that speeds up the growth cycle of skin cells leading to red, itchy scaly patches, most commonly on the knees, elbows, trunk and scalp. Psoriasis is a common, long-term (chronic) disease with no cure. It tends to go through cycles, flaring for a few weeks or months, then subsiding for a while or going into remission. Treatments are available to help you manage symptoms. And you can incorporate lifestyle habits and coping strategies to help you live better with psoriasis.
What are the symptoms of Psoriasis?
Psoriasis signs and symptoms can vary from person to person. Common signs and symptoms include:
• Red patches of skin covered with thick, silvery scales
• Small scaling spots (commonly seen in children)
• Dry, cracked skin that may bleed or itch
• 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. The most commonly affected areas are the
lower back, elbows, knees, legs, soles of the feet, scalp, face and palms. Most types of psoriasis go through cycles, flaring for a few weeks or months, then subsiding for a time or even going into remission.
What are the types of Psoriasis?
Plaque Psoriasis
The most common form, plaque psoriasis causes dry, raised, red skin
patches (lesions) covered with silvery scales. The plaques might be
itchy or tender, and there may be few or many. They usually appear on
elbows, knees, lower back and scalp.
Nail Psoriasis
Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail
growth and discoloration. Psoriatic nails might loosen and separate
from the nail bed (onycholysis). Severe cases may cause the nail to
crumble.
Guttate psoriasis
This type primarily affects young adults and children. It's usually triggered by a bacterial infection such as strep throat. It's marked by small, drop-shaped, scaling lesions on the trunk, arms or legs
Inverse psoriasis
This mainly affects the skin folds of the groin, buttocks and breasts.
Inverse psoriasis causes smooth patches of red skin that worsen with
friction and sweating. Fungal infections may trigger this type of psoriasis.
Pustular psoriasis
This rare form of psoriasis causes clearly defined pus-filled lesions that
occur in widespread patches (generalized pustular psoriasis) or in smaller areas on the palms of the hands or the soles of the feet.
Erythrodermic psoriasis
The least common type of psoriasis, erythrodermic psoriasis can cover
your entire body with a red, peeling rash that can itch or burn intensely.
Psoriatic arthritis
Psoriatic arthritis causes swollen, painful joints that are typical of arthritis. Sometimes the joint symptoms are the first or only symptom or sign of psoriasis. And at times only nail changes are seen. Symptoms range from mild to severe, and psoriatic arthritis can affect any joint. It can cause
stiffness and progressive joint damage that in the most serious cases may lead to permanent joint damage.
What causes Psoriasis?
Psoriasis is thought to be an immune system problem that causes the skin to regenerate at faster than normal rates. In the most common type of psoriasis, known as plaque psoriasis, this rapid turnover of cells results in scales and red patches.
Just what causes the immune system to malfunction isn't entirely clear. Researchers believe both genetics and environmental factors play a role. The condition is not contagious.
What can trigger Psoriasis?
Many people who are predisposed to psoriasis may be free of symptoms for years until the disease is triggered by some environmental factor. Common psoriasis triggers include:
• Infections, such as strep throat or skin infections
• Weather, especially cold, dry conditions
• Injury to the skin, such as a cut or scrape, a bug bite, or a severe sunburn
• Stress
• Smoking and exposure to secondhand smoke
• Heavy alcohol consumption
• Certain medications including lithium, high blood pressure medications and antimalarial drugs
• Rapid withdrawal of oral or systemic corticosteroids
What are the treatment options for Psoriasis?
Psoriasis treatments aim to stop skin cells from growing so quickly and to remove scales. Options include creams and ointments (topical therapy), light therapy (phototherapy), and oral or injected medication.
Which treatments you use depends on how severe the psoriasis is and how responsive it has been to previous treatment. You might need to try different drugs or a combination of treatments before you find an approach that works for you. Usually, however, the disease returns.
Topical Medications
• Corticosteroids – These drugs are the most frequently prescribed drugs for mild to moderate psoriasis. They are available in multiple dosage forms including creams, ointments, lotions, gels, foams, sprays, and shampoos. Long-term use or overuse of strong corticosteroids can thin the skin. Over time, topical corticosteroids may stop working.
• Vitamin D analogues – Synthetic forms of vitamin D, such as calcipotriene and calcitriol slow skin cell growth. This type of drug may be used alone or with topical corticosteroids. Calcitriol may cause less irritation in sensitive areas.
• Retinoids – Retinoids are a Vitamin A derivative aimed at reducing inflammation and slowing the rate at which skin cells develop plaques.
• Calcineurin inhibitors – Calcineurin inhibitors — such as tacrolimus and pimecrolimus — reduce inflammation and plaque buildup. They can be especially helpful in areas of thin skin, such as around the eyes, where steroid creams or retinoids are too irritating or may cause harmful effects. Calcineurin inhibitors are not recommended when you're pregnant or breast-feeding or if you intend to become pregnant. This drug is also not intended for long-term use because of a potential increased risk of skin cancer and lymphoma.
• Salicylic Acid – Reduces the scaling of scalp psoriasis. It can be used alone or in combination with other ingredients to enhance penetration of the skin.
• Coal tar – Reduces scaling, inflammation, and itching. It is available over-the-counter in many forms like soap, shampoo, and cream. However, it can stain clothing and bedding, and can have a strong odor.
Light Therapy
Light therapy is a first-line treatment for moderate to severe psoriasis,
either alone or in combination with medications. It involves exposing
the skin to controlled amounts of natural or artificial light. Repeated treatments are necessary. Talk with your doctor about whether home phototherapy is an option for you.
Oral or Injected Medications
If you have moderate to severe psoriasis or other treatments haven't worked, your doctor may prescribe oral or injected (systemic) drugs. Because of the potential for severe side effects, some of these medications are used for only brief periods and might be alternated with other treatments.
• Steroids – If you have a few small, persistent psoriasis patches, your doctor might suggest an injection of triamcinolone right into the lesions.
• Retinoids – Oral retinoids are used to reduce the production of skin cells. Side effects might include dry skin and muscle soreness. These drugs are not recommended when you're pregnant or breast-feeding or if you intend to become pregnant.
• Methotrexate – Usually administered weekly as a single oral dose, methotrexate decreases the production of skin cells and suppresses inflammation. People taking methotrexate long term need ongoing testing to monitor their
blood counts and liver function.
• Cyclosporine – Taken only for severe psoriasis, cyclosporine suppresses the immune system. Like other immunosuppressant drugs, cyclosporine increases your risk of infection and other health problems, including cancer. People taking cyclosporine need ongoing monitoring of their blood pressure and kidney function.
• Biologics – These drugs, usually administered by injection, alter the immune system in a way that disrupts the disease cycle and improves symptoms and signs of disease within weeks. Biologics must be used with caution because they carry the risk of suppressing your immune system in ways that increase your risk of serious infections. In particular, people taking these treatments must be screened for tuberculosis.
Lifestyle and Home Remedies
• Take daily baths – Bathing daily helps remove scales and calm inflamed skin. Add bath oil, colloidal oatmeal and Epsom salts to the water and soak for at least 15 minutes. Use lukewarm water and mild soaps that have added
oils and fats.
• Use moisturizer – After bathing, gently pat dry and 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. If moisturizing seems to improve your skin, apply it one to three times daily.
• Cover the affected areas overnight – Before going to bed, apply an ointment-based moisturizer to the affected skin and wrap with plastic wrap. When you wake, remove the plastic and wash away scales.
• Expose your skin to small amounts of sunlight – Ask your doctor about the best way to use natural sunlight to treat your skin. A controlled amount of sunlight can improve psoriasis, but too much sun can trigger or worsen outbreaks and increase the risk of skin cancer. Log your time in the sun, and protect skin that isn't affected by psoriasis with sunscreen with a sun protection factor (SPF) of at least 30.
• Apply medicated cream or ointment – Apply an over-the-counter cream or ointment containing hydrocortisone
or salicylic acid to reduce itching and scaling. If you have scalp psoriasis, try a medicated shampoo that contains coal tar.
• Avoid psoriasis triggers – Notice what triggers 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. If you have psoriasis, avoid alcohol. If you do drink, use moderation.
• Strive to maintain a healthy lifestyle – In addition to quitting smoking and drinking moderately, if at all, you can manage your psoriasis by being active, eating well and maintaining a healthy weight.
What is Low Dose Naltrexone?
LDN is a prescription drug that helps to regulate a dysfunctional immune
system. It reduces pain and fights inflammation. It is not a narcotic or a
controlled substance. It is an opioid receptor antagonist that is taken orally to block opioid receptors. An antagonist is a chemical that acts within the body to reduce the physiological activity of another chemical substance.
Naltrexone was approved by the FDA in 1984 for the treatment of opioid addiction, usually at a dose of 50-100mg a day. It blocks the receptors that opioids like oxycodone bind to negating the euphoric effect. However, at much lower doses, naltrexone has been used for autoimmune disorders like
Hashimoto’s disease as well as chronic pain.
For more information on how LDN works, please click here.
Image Credit: https://pubchem.ncbi.nlm.nih.gov/compound/Naltrexone
How does LDN provide relief?
Before we discuss how LDN works, we need to go over the role of endorphins in the body. Endorphins are opiate-like molecules in the body. They are produced in most cells in the body and are important regulators of cell growth and the immune system. The particular endorphin that has been found to influence cell growth is called Opioid Growth Factor (OGF). For an endorphin such as OGF to exert its beneficial effects, it must interact with the body’s cells. It does this by binding to a receptor on the surface of the cells.
Naltrexone is an orally administered drug that binds to opioid receptors. In doing so, it displaces the endorphins which were previously bound to the receptors. Specifically, by binding to the OGF receptors, it displaces the body’s naturally produced OGF. As a consequence of this displacement, the affected cells become deficient in OGF and three things happen:
1) Receptor production is increased, in order to try to capture more OGF.
2) Receptor sensitivity is increased, also to try to capture more OGF.
3) Production of OGF is increased, in order to compensate for the perceived shortage of OGF.
Since LDN blocks the OGF receptors only for a few hours before it is naturally excreted, what results is a rebound effect; in which both the production and utilization of OGF is greatly increased. Once the LDN has been metabolized, the elevated endorphins produced as a result of the rebound effect can now interact with the more-sensitive and more-plentiful receptors and assist in regulating cell growth and immunity. The elevated level of endorphins can result in an enhanced feeling of well-being as well as a reduction in pain and inflammation. The duration of the rebound effect varies from person to person but generally lasts about one day. This effect can only be utilized by taking a low dose of naltrexone and not a high dose or extended-release naltrexone.
What does the research show?
Research has been done over the years evaluating how LDN and its use in psoriasis. Some of the studies that have been published are smaller studies but show promise for the treatment of chronic pain using LDN. Studies include:
• Journal of the American Academy of Dermatology - found that LDN is effective in treating inflammatory skin conditions and easing itching.
• International Journal of Pharmaceutical Compounding - found LDN to be effective and safe for use in psoriasis while marked improvement in patients.
• Current Drug Targets - found LDN to be a promising alternative therapy or adjunct therapy for dermatological conditions
For a list of more studies, please click here.
What dosage forms are available?
LDN is available by prescription only from compounding pharmacies. It is available as an immediate-release oral capsule or a liquid. LDN is typically prescribed at doses from 0.001mg-16mg with the most common dose of 4.5 mg.
Ask your doctor or one of our compounding pharmacists if LDN is right for you.
Sources:
https://www.mayoclinic.org/diseases-conditions/psoriasis/symptoms-causes/syc-20355840
https://www.webmd.com/skin-problems-and-treatments/psoriasis/understanding-psoriasis-basics
https://www.mayoclinic.org/diseases-conditions/psoriasis/diagnosis-treatment/drc-20355845
https://www.medicalnewstoday.com/articles/retinol-psoriasis#how-it-helps
https://www.healthline.com/health/nail-psoriasis
https://www.psoriasis.org/guttate/
https://creakyjoints.org/symptoms/psoriasis-and-psoriatic-arthritis-connection/
https://pubmed.ncbi.nlm.nih.gov/30582992/
https://pubmed.ncbi.nlm.nih.gov/32196470/
https://pubmed.ncbi.nlm.nih.gov/30887922/
https://www.cdc.gov/psoriasis/index.htm#:~:text=Psoriasis%20is%20an%20autoimmune%20disease,normal%20tissues%20in%20the%20body.