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Psoriasis and Electrology: An Overview
By Richard J. Ashack, M.D.

*Note: This article was taken from Spring/Summer 1996 Perspectives.

About the Author
Dr. Richard J. Ashack is a Michigan native. He received his bachelor of Science degree from Central Michigan University and his Masters Degree in pharmacology from Butler University. After working as a pharmaceutical researcher for seven years, Dr. Ashack went on to earn his Medical Degree from the Indiana School of Medicine. He is a Board certified dermatologist. Dr. Ashack is the author of more than seven articles.

Purpose
The purpose of this article is to review the etiology, the patho-physiology, as well as the treatment of psoriasis, allowing you to have a more rational approach to electrolysis in these patients.

Background
Psoriasis is a chronic skin disorder in which there is a familial tendency in that 16-25 percent of patients that have psoriasis have another family member with it. It has been estimated that two percent of the American population has it, or about three to four million people.
   It is estimated that 150,000 new cases of psoriasis will be diagnosed each year. The name "psoriasis" is derived from the Greek word to mean "itch", and is caused by an overproduction of skin cells. Psoriasis clinically appear as very thickened red plaques with heavy silvery scale. The most common locations of psoriatic plaques include the elbows and the knees, as well as the lumbar spine.
   The realm of psoriasis can be from the very mild, in which patients have mild scalp flaking, all the way up to very severe disease in which almost the entire body can be covered with these very large red and silvery plaques. There is a percentage of patients that have intense itching that occurs with their disease, most times it is not symptomatic.

Cause Not Known
The cause of psoriasis is not known. It is felt to be a chemical malfunctioning in the skin cell production. It is known that in patients with normal skin, it takes 28 to 30 days for a cell to reach the surface of which only 60 percent of skin cells are dividing and 40 percent are resting. In psoratic areas it has been shown that it takes a cell 10-14 days to reach the surface, and 100 percent of the cells are dividing and none in the resting phase.
   Psoriasis can be triggered by cuts, scratches, or burns, including sunburn, as well as any area that is rubbed or abraded; this is called a Koebner reaction. Psoriasis can be triggered by infections such as strep throat, and by certain drugs, of which the most likely are beta blockers, as well as lithium.
   Special diets have not been successful in preventing recurrences or improving existing psoriasis. People who live in cold weather tend to have flare-ups more commonly in the winter due to dry skin and lack of natural sunlight.

Many Types
Psoriasis can occur in many different types. The classic, large plaque type is the very thick, silvery scale that is known to occur primarily on elbows, knees, groin, legs, and scalp. If the scale is picked off, pinpoint bleeding often occurs.
   Psoriasis can also occur in small, teardrop shaped erythematous plaques with silvery scale referred to as guttate psoriasis. This form most often accompanies a sore throat or upper respiratory tract infection.
Finger and toenails can also be very common markers for psoriasis. Typically, we see small pits in the nails that look like they have been hit by a hailstorm. There is also an oil-slick like look that occurs in the more lateral aspect of the nails. In addition, the nails may also become very thickened and then crumble, making them very difficult to treat.
   Inverse psoriasis is a term used to describe psoriatic plaques that tend to involve the fold areas, such as the armpits, the inguinal folds, or the folds under the breast. These areas tend not to have the very thick silvery scale, but are more likely to have layered plaques.

Psoriasis and Arthritis
It has been estimated that up to six percent of psoriasis patients have severe psoriatic arthritis, which can effect the large joints such as the knees, elbows, as well as the fingers and toes. This type of psoratic arthritis tends to be more asymmetric, which differs from that seen in rheumatoid arthritis.
It has been reported that the arthritis can wax and wane with the therapeutic success of the skin lesions. It is important to note that blood tests, which usually pick up a rheumatoid factor in rheumatoid arthritis, are negative in patients with psoriatic arthritis.
   Psoriasis is diagnosed by careful examination of the skin, hair, and scalp. Occasionally, a biopsy is performed to help evaluate the tissue histologically under a microscope. The exact method of treatment is dependent upon the patient's overall age, life style, the severity, as well as the distribution and type of psoriasis.

Treatment
There are multiple treatment modalities available to the physician and the patient. These include both topical and systemic medicines. The most traditional therapy for psoriasis and the mainstay as it exists today is topical steroids. These come in creams, ointment, lotions, and solutions- their different preparation is dependent upon the type of psoriasis, as well as the location.
   Patients that have psoriasis only of the hands can use a much more potent topical steroid ointment than someone with it on their face, genital, or fold areas. The mechanism by which the topical steroids work is to slow down the rapidly dividing cells of the skin to eliminate the plaques of psoriasis.
Steroid injections can also be very helpful. This treatment consists of injecting a low concentration of steroids right into plaques of psoriasis. Treatment of the scalp, as well as other hair-bearing areas, can be very difficult. Typically, the use of either tar-based shampoos or shampoos that contain topical steroid preparations are helpful. Selsun can also be very efficacious at times.
   Plain lubrication with mineral oil can be very helpful for loosening the very thick plaques of scale that exist on the scalp. Topical steroids that are in the form of solutions, gels, petroleum jelly-based ointments can also be used on the scalp.
   Coal tar has been used for more than 100 years to treat psoriasis topically. It has been shown to be very effective in slowing the rapidly proliferating cells; however, it can be very messy in that it can stain clothing, make a mess with respect to bathing, and has a significant odor.
Anthralin is another medicine that is available to treat plaque psoriasis. This can produce a burning sensation, as well as a discoloration of the skin. If used on the scalp, Anthralin can sometimes leave a purplish discoloration in very fair-haired patients.

Light Therapy
There are multiple treatment regimens that include light therapy. Both sunlight, as well as ultraviolet light used in psoriasis treatment centers can be very helpful for slowing down the proliferating skin cells. Light therapy often uses ultraviolet light that is responsible for sunburns. Because of this, UVB has to be used cautiously and only by a regulated psoriasis treatment center.
   Another psoriasis treatment consists of using a longer wavelength of light, referred to as ultraviolet A (UVA), which is less responsible for burning. UVA, when used in combination with a pill called Psoralen, is effective in up to 90 percent of patients with plaque psoriasis. This is given usually over several months to induce remission of the disease, and then gradually weaned with time.
   Another regimen that has been around for many years and is quite effective is referred to as Goeckerman treatment. This was named after a dermatologist who originally reported this in the early 1900's. This treatment combines coal tar in the form of baths or in combination with applications of ultraviolet light. This is usually done very intensively for a 2-6 week period and can induce remissions for a long period of time.
Systemic agents, which are available for patients who have very significant widespread disease, include Methotrexate, an anti-cancer drug. This medicine's mechanism is to disrupt the cell cycle so that it cannot replicate as fast. Because it is a cancer chemo-therapeutic agent, one has to follow blood studies very closely because bone marrow suppression can occur with this particular drug. In addition, liver side effects can be significant and have to be monitored regularly with both blood test, which examine the liver function, as well as periodic liver biopsies.

Vitamin A Useful
Retinoids have become more available for psoriasis. These are synthetic Vitamin A derivatives which have been shown to be effective against plaque psoriasis. There are many side effects of the retinoids, which can include dry, flaky, cracked skin; dry eyes; elevation of blood fats; the formation of bony spurs in the spine and; most importantly, women who take this cannot become pregnant because it is very potent agent in producing birth defects.
   There are other systemic therapies that are used less frequently for psoriasis, and they too are not without extensive side effects. Because of this, careful monitoring of the patient's blood for appropriate side effects is required.
   The most recent advancement is the use of the vitamin D analog called Dovonex ointment. Vitamin D is very important with respect to differentiation of cells in the skin. Dovonex, which is a chemically synthesized analog of natural Vitamin D, is very useful for slowing the proliferating cells of psoriasis. This topical treatment is showing great promise.
   Cyclosporine, which is a very potent immune boosting drug, has recently gained attention as a treatment for psoriasis. Cyclosporine, when taken orally, has been shown to induce psoriasis remission; however, because of the extreme side effects, patients have to be monitored very carefully. This drug is used primarily in a controlled environment, such as an academic center.

Use Caution
Because of the Koebner Reaction, psoriatic patients undergoing electrolysis should be treated with extreme caution. A plaque of psoriasis may result from any trauma, as noted earlier in our discussion. It is the author's opinion that a test should first be performed on a relatively inconspicuous patch of skin and, even if no reaction occurs, to proceed with caution.

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