|Cutis care - Psoriasis |
Thoughts and practical advice
Thoughts and practical adviceDownload Document "Thoughts and practical advice" (Doc 4MB)
Psoriatic skin under a magnifying glass
When psoriasis affects the skin or nails, it interrupts the process of keratinisation: i.e. the process that gives rise to the thin and compact stratum corneum of the epidernis, and the compact and transparent laminar covering of the nails.A compact stratum corneum is plastic (i.e. it can flex without cracking), whereas one that is affected by psoriasis is stiff and and subject to cracking upon movements. A healthy stratum corneum acts as a barrier against harmful external agents, whereas one that is psoriatic is permeable to everything: micro-organisms, environmental pollutants, and even water.
NORMAL STRATUM CORNEUM PSORIATIC STRATUM CORNEUM
NORMAL NAIL PSORIATIC NAIL
All of the above explains why psoriatic skin, regardless of therapeutic treatments, needs particular care and attention in order to minimise possible inconveniences in everyday life.
The same goes for the nail plate: when it is healthy, it is compact and impenetrable; when it is psoriatic, it becomes delaminated and can be easily penetrated by micro-organisms, dirt and water.
When psoriasis affects the scalp
Psoriasis often affects the scalp, which may even be the only affected site.
Scalp psoriasis is particularly irritating and uncomfortable: it is often itchy, continuously releases scales that can be seen on one’s clothes, it extends from the edge of the hairline and is thus visible, and makes people unwilling to visit a hairdresser.
psoriasis is difficult to treat but, if you do not want to use drugs, natural
reducing agents are an alternative.Natural
reducing agents work well in the treatment of scalp psoriasis. The
most widely used are colloidal sulphur (see page 20) and salicylic acid (see
page 20) formulated in evanescent creams without vaseline.  The
cream is applied in the evening and massaged in until it is completely
Anyone who is affected by scalp psoriasis should take particular care over hair washing.
When psoriasis affects the scalp
Shampoos are mixtures of tensioactive ingredients intended to de-grease
and wash the hair. However, such ingredients are also irritants, particularly
in the case of a psoriatic scalp.
The rules for hair washing are:
When psoriasis affects the nails
Nails affected by psoriasis undergo the same alteration as the stratum corneum.The laminar plates making the nails become detached from each other, and the whole nail becomes detached from the ungueal bed. The consequences are that the nail becomes permeable to external agents such as water, detergents, dirt and micro-organisms. As a result of the delamination, it becomes opaque and more fragile; as a result of the penetration of dirt or micro-organisms, it changes colour and takes on different shades of yellow, brown or black.
These changes cause discomfort, particularly if they affect the finger nails.
Nail psoriasis can modify the plates in an even more
In addition to the above-mentioned unaesthetic effects, psoriasis of the nails also causes function defects and complications. The main functional defect is loss of grip in the case of a deformed distal phalanx or the loss of an entire plate.
The main functional defect affecting the feet is a difficulty in walking when the big toenail becomes thickened, interferes with shoe uppers, and causes pain.
One complication that affects both hands and feet is perionyxis: i.e. infection of the tissue around the nail. This occurs because the cuticles do not form and the perionychia becomes permeable to water,detergents, dirt and micro-organisms.
How to manage psoriatic nails
1) Locally applied drugs have little effect on the course of nail psoriasis and are therefore of little help to patients. This is because the alterations in psoriatic nails are due to an alteration in the ungueal matrix. The matrix is located deeply, above the phalangeal bone, and can hardly be reached by drugs applied to the skin. As drugs are not effective, it is better to use natural reducing agents. Both sulphur and salicylic acid have considerable affinity for nails and peri-ungueal corneum tissue, and exert a reducing, antimicrobial and exfoliative action. Although it does not have any real therapeutic effect on nail psoriasis, vaseline-free, evanescent sulphur-salicylic cream  contributes to softening the laminar plate, facilitating the detachment of the accumulated scales underneath the nails, and protecting both the nail and perionychium from infections. Sulphur-salicylic cream  is applied once a day in small amounts, beginning the massage from the free border, then on the nail and finally the perionychium. The duration of treatment is unlimited.
2) It is known that exposure to the sun during the summer tends to lead to the regression of the nail damage caused by psoriasis. In order to improve the nails, the exposure does not have to be prolonged; the light energy of the summer is sufficient and so, if the affected nails are on the feet, it is advisable to wear sandals that allow the light to reach the toes. On the contrary, UV lamps are not very practical because, in order to obtain a positive result, it is necessary to attend a large number of sessions and, in the end, there is a risk of inducing damage caused by the UV rays
3) To wash hands and feet whose nails are affected by psoriasis, it is better to use a cleansing cream free of lauryl sulphate  instead of soap, and to wash them briefly and infrequently in order to avoid soaking the tissue and worsening the psoriasis.
4) In order to eliminate the longitudinal streaks, depressions and opacity, and improve the look of the nails, a professional nail-file should be used; there are some on the market coated with sapphire that are particularly efficient.
5) If the nail tends to grow vertically in an exaggerated manner, it is not possible to use a nail-file but necessary to consult a podologist. Podologists have special high-rotation, water-cooled files of various makes, which are capable of remodelling both the thickness and free border of the nail plate.
6) In addition to the above treatments, it is possible to try to hide the nail. The most common way (conventionally reserved for women) is to use nail varnish. In order to ensure a good result, it is necessary to file the nails using a standard or rotating nail-file before applying the varnish, which is better if it is dark and opaque.
7) However, when the nail is severely damaged by psoriasis, varnish is not enough and it is necessary to construct an artificial nail made of liquid resins that harden when they are heated or exposed to UV rays. Once hardened, a nail shape can be cut out.
In addition to its aesthetic function, the application of a resin nail also serves to keep the ungueal bed flat, otherwise the distal phalanx would tend to curve upwards obstructing the growth of the mail itself. If this happens to the big toe, it can cause pain on walking because of the opposition between the pulp of the toe and the edge of the nail.
When psoriasis affects the body
Psoriasis affects the body in various forms and in various areas; the most common form is plaque psoriasis, which mainly affects the elbows, knees and sacral region.
However, psoriasis can present polymorphously:
• as a single patch or plaque
• as small but grouped plaques
• as even smaller and disseminated plaques (drop-shaped)
• as large plaques in abstract configurations.
If we look at a psoriatic plaque through a magnifying glass, we can see an inflammatory base covered by scales, some of which are adhering to the skin, some are raised, and some already detached. The whole forms microfissures that intermingle with each other.
• Once dried, the plaque should be treated with a
polyethylene glycol (PEG) or polydecene (D) ointment – so-called Emollient Ointment – Extreme - 
that are simultaneously capable of absorbing residual dampness,
reducing bacterial growth, restoring flexibility to the stratum corneum, and
favouring the detachment of the scales.
These are the considerations leading to the following rules for everyday washing:
• A shower is better than a bath because contact between
the water and the plaques is shorter and the scales absorb less.
After washing, it is necessary to dry the plaques
carefully in order to remove as much water as possible because dampness favours
bacterial growth, which leads to further plaque irritation.
In brief, for everyday hygiene:
When psoriasis affects the body
Using natural reducing agents
When the psoriasis is minimal and it is wanted to avoid having recourse to drugs, or in the intervals between drug treatments, or when drugs are contraindicated or have failed to lead to satisfactory results, it is possible to use natural reducing agents. These are natural active ingredients which, when applied to the skin, reduce psoriatic growth. There are many of these, but the most widely used and the ones for which there is the greatest amount of clinical documentation are:
• sulphur; • salicylic acid; • ichthyol sulphonate; • mineral tar
Sulphur is the oldest anti-psoriatic natural active ingredient. It is known to be rich in keratines, the proteins of the stratum corneum, but it is not known exactly how it is capable of controlling inflammatory states such as seborrhoic dermatitis and psoriasis. Sulphur-based pastes or sulphurous water baths have been used to treat skin conditions and psoriasis since ancient times.
Salicylic acid, which was initially extracted from the bark of willow trees, has been used since ancient times because of its curative properties. On the skin, it has an antiseptic, antifungal, keratolytic and reducing action.
The combination of sulphur and salicylic acid Although chemically very different, sulphur and salicylic acid have similar dermatological curative properties that potentiate each other, which is why they are used together in what is known as sulphur salicylic cream
The sulphur salicylic cream used as a reducing agent in seborrhoic dermatitis and psoriasis must contain sulphur in its colloidal form and be devoid of vaseline . The concentration of the two active ingredients must not be more than 2%. This cream leads to good results in psoriasis affecting the scalp or delicate areas such as the ears, genitals, nails, etc
Ichthyol sulphonate is a compound that first formed 200 million years from marine sediments, and is today extracted from mines in France and the Tyrol. It is a dense and dark liquid with a characteristic smoky odour that has antiseptic, anti-inflammatory and anti-pruritic properties. In psoriasis, it is used in the form of a cream  above all on inflamed and itchy areas. It can be used together with other natural reducing agents, or alternated with them.
Mineral tar (commonly known as coal tar) is derived from the distillation of fossil carbon. It is a highly viscous liquid with a characteristic penetrating smell, and is used in an evanescent cream at a concentration of 4% . The potent psoriasis-reducing action of 4% coal tar cream is as active or even more active than cortisone, but there are some drawbacks. It cannot be used on the scalp because it interacts with hair and turns it violet; it is not very well tolerated in delicate areas such as the face and genitals; it has an intense smell; it indelibly stains clothing; and it acts as a potent photosensitiser because it reacts with sunlight. For this last reason, it is only used in the winter.
• Suggestions for treatment with natural reducing agents
• Timing and possible variations – reducing + scaling regimens
• Timing and possible variations – double reducing regimens
When psoriasis affects the hands and feet
Psoriasis sometimes preferentially or exclusively affects the palms of the hands, the soles of the feet, or both locations.
PALMAR PSORIASIS PLANTAR PSORIASIS PALMO-PLANTAR PSORIASIS
Palmo-plantar psoriasis has various clinical forms, the most frequent of which are erythematous, hyperkeratotic, exfoliative and dyshidrotic psoriasis
HYPERKERATOTIC FORM EXFOLIATIIVE FORM DYSHIDROTIC FORM
When psoriasis affects the hands and feet
When psoriasis affects the palms and soles, it creates new management problems because one of the characteristics of even the mildest forms of palmo-plantar psoriasis is the presence of cracks or rhagades. This is due to the fact that a poorly organised stratum corneum can never have the necessary elasticity to cope with the movements of the hands and feet. The cracking may be clearly visible or not, as in the case of the microfissures or microrhagades in the examples below.
When cortisone treatment is prescribed
Cortisone is still the most widely used drug for the treatment of localised (particularly palma-plantar) psoriasis. Unfortunately, cortisone is the least suitable drug for treating a chronic dermatitis such as psoriasis because of its known unwanted effects of tachyphylaxis and rebound.
Tachyphylaxis is a form of desensitisation over time that means an increasing amount of drug has to be administered in order to obtain the same therapeutic result.
In the case of psoriasis, this means starting to control the disorder by applying cortisone once a week, but then having to apply it everyday or more than once a day, and sometimes still being unable to control it.
Rebound is the term used to describe the fact that, when cortisone is stopped, the dermatitis markedly worsens. In the case of palmo-plantar psoriasis, stopping cortisone leads to swelling, burning, the opening of the cracks, and the appearance of blisters or blebs.
Controlling rebound after the discontinuation of cortisone is particularly difficult, and often exposes the patient to considerable suffering. For this reason, before stopping the drug, it is necessary to left the need to do so.
Psoriasis is an inflammatory state of the skin, and worsens in the presence of other stimuli of cutaneous inflammation. In other words, it must be soothed and not stimulated. When it affects the hands and feet, it is particularly difficult not to cause further stress on the skin: it is enough to think of walking and the everyday handling of common objects. The philosophy of “placating” palmo-plantar psoriasis therefore involves eliminating as many pro-inflammatory stimuli as possible. The most important of these is contact with water and detergents. Water is itself an irritant of the psoriatic state: it can penetrate between the scales and in the cracks, making them damp and thus favouring microbial growth and the consequent irritation. The tensioactive ingredients in detergents are further pro-inflammatory stimuli that psoriatic skin needs protecting against. Even dust causes irritation and needs to be kept away from the skin.
Wash without getting your hands and feet wet. The idea is to prevent water and detergents from coming into contact with psoriatic skin. In the case of the hands, the recommendation is to wear vinyl gloves , which are impermeable to water and do not irritate the skin themselves.
However, they do not adhere to the wrists, and so it necessary to take care that water does not enter the gloves while you are washing. The same vinyl gloves should be worn every time you are likely to get your hands dirty (so that you do not have to wash then afterwards), or to protect them from dust. When it is necessary to wash your hands, such as before eating or after having used the toilet, it is necessary to use a “dry” disinfectant. One possibility is an acqueous solution of benzalconium chloride , which has a simultaneously cleansing and disinfecting action: soak some cotton wool with the disinfectant, squeeze it to eliminate the excess liquid, and then rub it on the hands
As far as the feet are concerned, put a stool in the shower so that you can sit on it when washing the rest of your body while keeping your feet out of contact with the water. You can then wash your feet in the same way as your hands
Using natural reducing agents on palms and soles. It is advisable to treat palmo-plantar psoriasis with the same natural reducing agents as those described in the previous chapter. The agent should be applied in the evening taking particular care to massage it in well because the thickness of the stratum corneum on the palms and soles limits the absorption of topical products to a minimum. If you use coal tar, you should wear light cotton gloves or socks when sleeping in order to avoid staining the sheets, but this is not necessary if you use one of the other agents.
Protect your hands during the day.
During the course of the day, your hands come into contact with various objects or substances that could aggravate the psoriasis, and this has given rise to the idea of using something to protect the hands. Although protective creams acts as stress factors on psoriatic skin and cannot be applied, what have proved useful are ointments containing polyethylene glycol (PEG) . These ointments have the advantage that they form a barrier between the skin and the external environment, but still allow the skin to breathe. The suggested PEG ointment  also contains allantoin, a substance that favours the cicatrisation of the fissuring, and can be applied a number of times during the day.
When palmo-plantar psoriasis is in remission. Once the remission of palmo-plantar psoriasis has been obtained, care needs to be taken when handling potentially irritating substances in order to avoid “re-awakening” the condition. The best suggestion is to continue wearing vinyl gloves as necessary  and usiing lauryl sulphate-free cleansing cream  instead of normal soap and shampoos.
Psoriasis in the summer
In the summer, psoriasis tends to improve or completely regress, mainly due to the effect of sunlight. However, it must be borne in mind that not all forms of psoriasis improve with the sun, and that some actually worsen. Nevertheless, it can be estimated that the sun is beneficial in 80% of cases
The sun acts as an anti-psoriatic agent in various ways: it increases the synthesis of vitamin D, which has an anti-psoriatic action; decreases the rate of growth of the cells damaging DNA; and reduces inflammation by distancing lymphocytes. It is probable that it also acts against psoriasis by releasing some brain neurotransmitters – the same ones that make us more good humoured.
The sun can therefore be considerd another natural reducing agent. However the same ultraviolet (UV) rays that are responsible for a large part of the sun’s anti-psoriatic action are also the cause of skin cancers, and so it is necessary to keep a balance between costs and benefits. Finally, it is worth remembering that sunburn (i.e. excessive exposure to the sun before beginning to acquire a tan) can “re-awaken” psoriasis – and the same goes for exposure to a UV lamp. It is therefore necessary not to get carried away by the urge for a sun cure, but to take care when sunbathing – not least because sun protection creams and lotions must be avoided.
Psoriasis in a spa environment
Many spas, particularly those in Italy, have springs
of sulphurous thermal water in which the sulphur may be free or combined with
other substances. Various hydrological schools have classified sulphurous
waters in different ways. The Italian school identifies sulphurous waters as
those containing at least 1 mg of free H2S (1 hydrogen sulphide
degree 0.001 g, equal to 0.658 ml di H2S), and distinguishes:
In an attempt to strengthen spa therapy for psoriasis
we has recently proposed the following combined treatment:
The next day, the same treatment is repeated
In a study recentelly carried out, this treatment regimen led to significantly better results after two weeks than treatment based solely on the baths.
We also recommend this type of treatment for people who have the opportunity to visit a spa. In the summer, this treatment can be complemented by heliotherapy, but we personally do not recommend the use of UV lamps.
Despite some positive reports, the application of muds, algae and hay does not seem to lead to substantial benefits in the treatment of psoriasis.
Psoriasis stress and society
How to feel at ease, and how to disguise psoriasis
Many people sustain that psoriasis is purely psychosomatic; we think it is more correct to say that it is a disease that is aggravated by stress but has different bases.
In any case, in the everyday experience of both physicians and patients, there is a clear relationship between psoriasis and stress. What should be considered is how much psoriasis induces stress in patients, regardless of how much stress has influenced the onset of psoriasis. If psoriasis generates stress, in addition to treating the skin, dermatologists must try to attenuate the stress or the treatment will have no effect.
Stress Psoriasis Stress Psoriasis...
Unfortunately, everyday practice makes it all too plain how difficult it is to attenuate the stress generated by psoriasis, and that even recourse to anxiolytics or hypnogens often has no effect (as well as being generally poorly accepted by patients).
The stress generated by society, work, the family, etc. is even more unmanageable and, from this point of view, the picture is as disappointing as it is worrying.
Luckily, given that any worsening is easily perceptible, psoriatic patients are themselves well aware of the role of direct or reflected stress in the genesis of their psoriasis.
Dermatologists must therefore remember and repeat these concepts, and help their patients to reflect upon the need to seek all possible and sustainable means of escaping stress.
How not to be stressed by psoriasis
The rules are:
How to disguise psoriasis
When visible, psoriasis becomes an aesthetically displeasing sight that patients may not be able to tolerate. The most common case is psoriasis of the nails, although it can be treated/disguised in many ways. The nail plate can be filed to eliminate the distorsions and (partially) the stains; it can be covered with coloured or opaque nail varnish; it can be hidden by a false resin nail.If the psoriasis affects the face, topical therapies can be applied in the evening and, in the morning, make-up can be used to eliminate the the erythematous nuance that makes it noticeable.
In the case of scalp psoriasis, it can be suggested to keep your hair short, or long but tied back, and to wear light-coloured clothing and not black or navy blue.
Recommended products according to clinical experience
1) MOST Cream 2 S (MOST Technical Cosmetics, Milan. most-tc.com)
2) MOST Dermictiol Shampoo (MOST Technical Cosmetics, Milan. most-tc.com)
3) MOST Cleansing Cream (MOST Technical Cosmetics, Milan. most-tc.com)
4) MOST Emollient Ointment – Extreme (MOST Technical Cosmetics, Milan. most-tc.com)
5) MOST Dermictiol Cream (MOST Technical Cosmetics, Milan. most-tc.com)
6) Magistral preparation of 4% coal tar in evanescent cream made up by a pharmacist upon the prescription of a dermatologist*
7) Disposable vinyl gloves available in boxes of 100 in S, M, L sizes
8) Disintyl 240 ml (Zeta Farmaceutici, Vicenza. zetafarm.it)
9) MOST PEG Ointment (MOST Technical Cosmetics. Milan. most-tc.com)
* Pharmacists may have difficulty in obtaining coal tar, and so it is sometimes necessary to apply to a hospital pharmacy