Psoriasis - Diagnosis And Therapy

2023 Author: Wallace Forman | [email protected]. Last modified: 2023-08-25 11:04

Psoriasis: Diagnosis & Therapy

An early diagnosis and targeted treatment can help to improve the further course of the disease and the quality of life, as well as to prevent complications. The range of therapies includes nurturing basic therapy, externally applied drugs, phototherapy and internal drug therapies. The application takes place depending on the severity of the disease according to a kind of step-by-step plan, with many different forms of therapy being combined. In special cases, spa and bath therapies or inpatient treatment can also be useful.

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A detailed examination of the affected skin areas usually provides the diagnosis (1). A skin sample (biopsy) is only required in exceptional cases. To do this, a small piece of skin is removed and examined under a microscope. The doctor assesses the severity of the disease and creates a treatment plan together with the patient.

Determination of the severity

The severity of the physical symptoms of psoriasis vulgaris is determined using special parameters. A simple indication of the percentage of the diseased body surface is the "Body Surface Area" (BSA). The "Psoriasis Area and Severity Index" (PASI) is often determined in clinical studies. This index takes into account the extent of the disease, the redness and the thickness of the plaques and scaling. The disease-related quality of life is determined with the dermatological quality of life questionnaire (DLQI).

In Europe the following definition applies:

• Mild psoriasis: BSA ≤10 (a maximum of ten percent of the body surface is affected) and PASI ≤10 and DLQI ≤10.
• Moderate to severe psoriasis: BSA> 10 or PASI> 10 and DLQI> 10.

How is psoriasis treated?

Psoriasis is causally incurable. However, long-term freedom from symptoms can usually be achieved with suitable therapies (1). The primary therapeutic goals are to reduce inflammation and to inhibit the excessive cell proliferation of the epidermis and, as a result, to heal the skin lesions.

The following treatment options are available:

• Basic therapy with moisturizing and nourishing creams, ointments or lotions,
• local external drug therapy,
• Phototherapy (treatment of the skin with specific wavelengths of natural and artificial UV light),
• internal (systemic) therapy in the form of tablets, injections or infusions as well
• other therapies.

Stage scheme of psoriasis treatment

A step-by-step plan is often used depending on the severity of the disease. The treatment begins with local (topical) therapy, then moves on to phototherapy and ultimately to systemic therapy. The treatment is individually tailored to the patient and the course of the disease and changed if necessary.

• If only a few small areas of the body are affected, external therapies are carried out. Photo therapy is usually supplemented with increasing expansion or insufficient response.
• If the psoriasis is widespread or if external and photo therapy do not respond adequately, internal and external therapy may be combined.
• If there is no improvement or if there are intolerances or contraindications, biologics (new targeted systemic drugs) can be used. Combined therapy is almost always carried out for moderate to severe forms.
• After drug therapy or phototherapy, the skin needs basic therapy in order to stabilize the good condition of the skin. For this purpose, moisturizing and nourishing creams, ointments or lotions without active ingredients are used. They improve the condition of the skin and help to extend the symptom-free period. The basic therapy is an important part of every therapy concept for psoriasis.

Basic therapy

The basic therapy of psoriasis vulgaris includes the local (topical) application of active ingredient-free ointment bases with moisturizing and nourishing effects as well as preparations with urea and salicylic acid (each in a concentration of three to ten percent). The basic therapeutic care is an important part of the complementary treatment of psoriasis both in the acute stage and in the follow-up treatment of the healing skin. It helps to restore an intact barrier. In most cases, however, basic therapy is not sufficient as the sole treatment. It can be combined with all therapies.

External drug therapy

In local therapy, active ingredients in the form of ointments, creams, tinctures or sprays are applied directly to the skin. They are mainly used for mild to moderate psoriasis. Depending on the preparation, the effect becomes apparent after a treatment period of one to a few weeks. The most commonly used substances are:

• Cortisone-like preparations (corticoids): Corticoids are among the most frequently used and externally most effective drugs. They are used in particular when there is high inflammatory activity and on certain parts of the body. It is recommended to limit the therapy to a few weeks or to combine it with other active ingredients (especially vitamin D analogues, urea and photo light).
• Vitamin D analogues: When used properly, synthetically produced vitamin D analogues (calcipotriol and tacalcitol) are very well tolerated even in long-term treatment. Unwanted side effects can include skin irritation, burning, itching and redness, especially on sensitive skin areas (hairline, face and armpits).
• Dithranol (cignoline or anthralin): The concentration is initially selected to be low and increased steadily every several days. Alternatively, a “minute therapy” with a short exposure time and subsequent washing off of the dithranol can be carried out once a day. Mild or moderate irritation to the skin is an indication of the effectiveness of the treatment. If the skin reaction is too strong, the intensity may have to be reduced - at least temporarily. Another disadvantage is the severe discoloration of the skin, clothing and sanitary facilities.
• Calcineurin inhibitors: Tacrolimus and pimecrolimus are not approved for the treatment of psoriasis, but are also recommended by doctors outside of the approval (off-label use), particularly for facial psoriasis. They have anti-inflammatory and immunomodulating effects.

Phototherapy

Phototherapy (light therapy) is used for moderate to severe psoriasis (especially with large areas) that do not or no longer react to topical methods. The aim is to slow down the growth of skin cells. Various spectra of the UVB and UVA wavelength range are used to treat psoriasis vulgaris.

If the phototherapy is carried out by specially trained personnel, the tolerability is very good and there are seldom direct side effects. Therefore it can also be used during pregnancy and in children. However, long-term and very frequently repeated light therapy increases the risk of premature skin aging and the development of skin tumors. Therefore, phototherapy is not recommended for long-term treatment.

Natural sunlight should be avoided during therapy. Since certain medications can interact with UV light therapy, the doctor should always be informed about the use of medication.

• UVB light therapy: The skin is regularly irradiated with an artificial light source of a certain wavelength for a specified period of time. Phototherapy is carried out by resident dermatologists or in special outpatient departments. The use of the excimer laser, which emits monochromatic UVB light with a wavelength of 308 nm, can be recommended for the targeted treatment of individual psoriatic plaques.
• PUVA light therapy (photochemotherapy): The initial administration of a photosensitizer (psoralen) is combined with the subsequent exposure to light, usually in the UVA wavelength range. The photosensitizing agent is taken before the phototherapy either as a tablet, applied to the skin (cream PUVA) or used as a bath solution (bath PUVA). PUVA therapies are more effective than UVB therapies, but they increase the risk of skin cancer more.

Therapy for internal use

If local therapies do not have an adequate effect, systemic therapies (internal use) are used. They are taken orally (e.g. in tablet form) or given as an injection or infusion. The effect only sets in a few weeks after the start of therapy.

Retinoids (e.g. acitretin), methotrexate, ciclosporin, fumarates and, as the most modern group, biologics (adalimumab, brodalumab, certolizumab, etanercept, guselkumab, infliximab, ixekizumab, risankizumab, secukinumab, tildrakizumab) are used. These so-called targeted active ingredients are only used when other forms of treatment have not shown sufficient therapeutic success, are incompatible or contraindicated. Many of them are highly effective and their security is proven by numerous register data (2). Some modern biologics can also be used during pregnancy and breastfeeding (3).

Biologics must not be used in severe infections, as they can weaken the immune system.

If infections occur during treatment, you must inform your dermatologist immediately.

Another therapeutic option is the phosphodiesterase inhibitor apremilast. This so-called small molecule in tablet form has the effect that fewer substances are formed in the inflammatory cells that stimulate or maintain inflammation.

Other therapies

Climate and bath therapies

As part of a treatment concept, climate therapies are particularly suitable for patients with psoriasis vulgaris that has been in need of therapy for years, not for acute or short-term therapy.

On the one hand, this involves longer spa stays in sunny areas (heliotherapy) and bath therapy (balneotherapy) either in natural waters (e.g. at the Dead Sea) or in natural waters containing mineral water (healing springs). During treatment stays, the psychological burden of illness is often reduced because the stigmatizing effect of visible symptoms in the circle of other sick people is eliminated.

Inpatient treatment

Treatment in the hospital can be useful or even necessary in the following situations:

• if outpatient therapy procedures carried out under specialist treatment can be proven to be unsuccessful.
• if there is a massive impairment of the quality of life due to psoriasis vulgaris, especially in visible areas, or severe impairment of performance, e.g. in the case of illness of the hands and feet in the corresponding occupations
• in the case of complications from concomitant diseases such as diabetes mellitus and other organ diseases as well as severe physical disabilities
• in all emergency and special cases of psoriasis vulgaris such as acute erythroderma, psoriasis vulgaris cum pustulatione and massive eruptive attacks, especially with general symptoms.

What can i do on my own?

Anyone who has decided on a therapy together with the doctor can make a significant contribution to the success of the treatment:

• It is important to stick to the therapy plan as closely as possible.
• The doctor should be informed about any intolerances or other special features in the course of treatment. Even supposed little things can be important.
• There are some factors that have been shown to have an adverse effect on treatment. It is important to avoid smoking, excessive alcohol consumption, being very overweight, stress, strong mechanical loads on the skin and sunburns as much as possible.
• Women with psoriasis should definitely talk to their doctor if they wish to have children or if they are planning or have already become pregnant, as some psoriasis therapies may not be administered during and sometimes longer before pregnancy.

Whom can I ask?

It is important to consult a general practitioner or a specialist in dermatology as early as possible in the event of persistent symptoms such as reddening of the skin, flaking and itching, etc. If joint problems occur and the diagnosis of psoriatic arthritis is confirmed, a coordinated diagnosis and treatment should be carried out by the specialist in internal medicine with a focus on rheumatology and by the dermatologist.

Climate and bath therapies are usually carried out in specialized centers with appropriately trained staff.

How are the costs going to be covered?

The e-card is your personal key to the benefits of the statutory health insurance. All necessary and appropriate diagnostic and therapeutic measures are taken over by your responsible social insurance agency. A deductible or contribution to costs may apply for certain services. You can obtain detailed information from your social security agency. Further information can also be found at:

• Right to treatment
• Visit to the doctor: costs and deductibles
• What does the hospital stay cost?
• Prescription fee: This is how drug costs are covered
• Medical aids & aids
• Health Professions AZ
• and via the online guide to reimbursement of social insurance costs.

In order to get a spa stay, e.g. at the Dead Sea, approved by the social insurance agency, you have to submit an application. The form required for this is available from specialists in dermatology. The doctor fills out the application and sends it to the responsible social insurance institution (health insurance, pension or accident insurance).

If the social security agency approves the stay at the spa, most of the costs will be covered. The patient pays a deductible depending on the income. In principle, a spa stay is approved a maximum of twice within five years.