- When Psoriasis Affects Your Feet
- Managing Psoriasis Symptoms of the Feet
- Medical Psoriasis Treatment for Feet Psoriasis
- Best home remedies for Psoriasis
- The psoriatic foot
- Give Them a Hand: Patients With Hand and Foot Psoriasis Require Special Attention
- Psoriasis of the palms and soles
- What is psoriasis?
- How does psoriasis affect the palms and soles?
- Clinical features of palmoplantar psoriasis
- What causes palmoplantar psoriasis?
- How is the diagnosis of palmoplantar psoriasis made?
- What is the treatment for palmoplantar psoriasis?
- Is That Rash Psoriasis, or Is It Something Else?
- When psoriatic disease strikes the hands and feet
When Psoriasis Affects Your Feet
Managing Psoriasis Symptoms of the Feet
“About 10 percent of people are born with genes that could cause psoriasis, but only about 2 percent of people actually get it,” Tung says. “Some things that could trigger psoriasis include stress and injury. People who have psoriasis of the feet or hands can easily trigger psoriasis symptoms with injury, since these are areas that are constantly used and exposed. It’s also important for people with this kind of psoriasis to baby their feet and hands, since cracking of the skin can lead to infection.”
Hands and feet psoriasis symptoms include dry, cracked, irritated skin and — in the case of palmoplantar pustulosis — pus-filled blisters. These psoriasis symptoms are more common in women than men, usually affect only adults, and can interfere with both work and leisure activities.
These home psoriasis treatment tips can help:
- Stop smoking. Smoking is a psoriasis trigger, and is bad for your overall health, too.
- Limit alcohol intake; alcohol seems to aggravate psoriasis.
- Wear comfortable shoes, and gloves when needed, that are made from natural fibers.
- Avoid injury as much as possible. “You could try protecting your feet with padded soles and thick cotton socks,” advises Tung.
- About twice a day, soak your hands or feet in warm water, pat them dry, and then cover them with a moisturizer, like petroleum jelly or colloidal oatmeal, to lock in moisture. “Ask your dermatologist to recommend a moisturizer for you,” says Tung.
- Cracking of the skin can be helped by using a cyanoacrylate adhesive (superglue) to reduce splitting and speed healing.
- After moisturizing, cover your feet or hands with a waterproof dressing for a few hours or overnight.
Medical Psoriasis Treatment for Feet Psoriasis
“Hand or feet psoriasis treatments usually start with topical ointments and progress to light therapy or, in really difficult-to-treat cases, injections of medications that block immune cells,” Tung says.
Medical options that may help include:
- Topical Steroids These are usually used for up to a month at a time. Steroids need to be strong to work on thick palms and soles, so they will need to be prescribed by your dermatologist.
- Topical Ointments Ointments derived from vitamin A and vitamin D can be used to slow down skin cell growth. “These are not the same as the vitamins you take by mouth,” Tung says. “They are strong medications that need to be monitored by your dermatologist.”
- Ultraviolet Light Treatment Light therapy slows down skin cell production in psoriasis and knocks out the immune cells causing the inflammation and is the next step in difficult-to-treat cases. “Your doctor can prescribe these light treatments two to three times per week,” Tung says. “In some cases, ultraviolet light can be combined with a topical medication that increases the effect.” Oral medication (psoralen) may also be used with light therapy.
- Oral Medication These included Vitamin A derivatives and Otezla (apremilast). “Otezla works on the inflammation without suppressing the immune system throughout the body,” says Tung.
- Biologics. These drugs that block the immune system may be suggested if other treatments aren’t working. “These medications are given by injection and are most likely to be needed for patients with more extensive or resistant psoriasis,” says Tung. “Since hand and foot psoriasis can be disabling, the more aggressive treatment may be warranted even though limited in extent.”
Having psoriasis on your feet or hands can make everyday activities difficult. “This type of psoriasis can be hard to treat and usually requires a combination of treatments,” Tung says. “Once you get the symptoms under control, things will get better, but count on being best friends with your dermatologist for a while.”
Best home remedies for Psoriasis
Psoriasis is a skin condition which normally appears on various parts of the body like knees, elbows, scalp, and the torso. The condition involves thick, red skin with silver-white patches called scales. In some cases these scales may be itchy and painful, and they sometimes crack and bleed. There is no known cure for psoriasis so even though these remedies would provide relief, it’s best to consult your dermatologist before trying anything.
Home remedies for psoriasis
Plastic wraps are an effective remedy when it comes to psoriasis. People suffering from this skin condition wrap the affected area with plastic covers, mostly after applying their prescribed medication or ointment. This is done to help the body hold onto the vital natural oils and water. Everything remains airtight and sealed, preventing unnecessary scratching on the affected area.
Sea salt like Epsom salt and water is another good remedy to treat psoriasis. Soaking in this combination will ensure removal of thick scales caused due to psoriasis, thus ensuring a deeper penetration of the medication into the skin. Epsom salt, known for its relaxing and exfoliating properties, in combination with lukewarm water is the ideal solution to provide relief from psoriasis.
By soaking or spraying apple cider vinegar to psoriasis affected area, you can reduce the itching, pain and burning sensation to a great extent. This popular disinfectant is known for its therapeutic properties and greatly benefits people suffering from this condition.
Drinking a combination of bitter gourd juice and lime first thing in the morning on an empty stomach can help provide relief from psoriasis. Although, recommended by dietitians, it takes about 5-6 months to show effective results.
Tips to control psoriasis
1. Symptoms of psoriasis can be treated by adding some additional dietary supplements to your routinely diet. Vitamin D, Aloe vera, Fish oil are a few supplements which may help ease psoriasis symptoms.
2. Although there is no shortage of humidity in our country, a humidifier can help with psoriasis. To prevent dry skin, a humidifier would keep the air in your home and office moist.
3. Avoid using soaps, perfumes and body washes that have too much additives in them. Most of these personal care products tend to have a variety of dyes, chemicals and fragrances which can aggravate the symptoms. Choose products which are labeled for sensitive skin. Using moisturizers made specifically for sensitive skin can keep the skin supple and psoriasis at bay.
4. Keeping a check on your diet is an effective method to control psoriasis. Eliminate fatty snacks and red meat. Add nuts, seeds, cold water fish and foods rich in omega-3 fatty acids. With an ability to reduce inflammation, they’re the perfect foods for you psoriasis.
5. Light therapy is yet another form of relief for people suffering from psoriasis. The procedure involves shining ultraviolet light on the affected skin. These sessions should be regularly scheduled and conducted under the supervision of an experienced doctor.
6. Stress has sadly become an integral part of our so called fast paced life. Everyone is under some level of stress at some point of your life. A condition like psoriasis can be a source of great stress and can often worsen the conditions of psoriasis. Try yoga and meditation. Most importantly, have a positive attitude towards your condition and life.
7. Dermatologists recommend using a prescription cortisone cream to treat psoriasis.
Celebrities and their treatment for psoriasis.
The world’s most famous reality star suffers from this disease as well. Kim Kardashian, the reality star, contour queen and businesswoman manages the breakouts by following a strict diet and a night time routine of applying cortisone cream to her itchy skin daily.
The star has also followed crazy home remedies as well. She applied her sister’s breast milk all over her legs. As crazy as it sounds, experts believe lactic acid in milk actually has many skin benefits. Breast milk has the proteins that soothe and coat inflamed skin. Although, there is no proof on how effective it would be to provide relief from psoriasis.
Suffering from the same disease, Kim’s mother, Kris used natural spring water to treat her skin condition. Experts believe that it isn’t as uncommon and using spring water actually works. This is due to the high levels of minerals like sulfur or selenium which can have a calming effect on psoriasis. Another good option is dead sea water, due to the high levels of magnesium salt which is known for reducing inflammation.
Crazy as these remedies sound, it’s not exactly feasible for a commoner. Even if you do decide to try out such celebrity remedies, be sure to consult your dermatologist in advance.
The psoriatic foot
For general foot care, personal hygiene is important, particularly in avoiding fungal and viral infections. Change shoes and socks regularly, avoid shoes which are ill-fitting or cause bad posture. If you are overweight, losing weight could relieve the pressure on your joints and improve your walking gait.
If you are diagnosed with psoriasis, develop a treatment regime that works for you; often, applying treatment after a bath or shower, along with the use of an emollient, can make the process easier.
If you have nail involvement, keep nails trimmed and clean. If they are thick, try trimming them after soaking them in a bath or shower, as this makes them softer and easier to cut. Alternatively, seek an appointment with a chiropodist, which is often available via the NHS.
If you have psoriatic arthritis, it is important to rest inflamed joints. Sourcing footwear that supports the foot and helps to reduce the pressure on the inflamed areas can help, as can inner soles and orthotic supports. Once again, a chiropodist is best placed to advise you.
This article is adapted from The psoriatic foot leaflet.
Always consult your doctor or healthcare provider.
Give Them a Hand: Patients With Hand and Foot Psoriasis Require Special Attention
Abstract and Introduction
Hand and foot psoriasis impairs patients´ ability to function, impacts them financially, and chips away at their self-worth. Dermatology nurses play an important role with these patients in improving their quality of life through support, counsel, education, and meeting their medical and emotional needs.
Psoriasis is an autoimmune disorder that occurs when skin cells grow abnormally, producing thick, red, scaly, and inflamed patches on the skin. Plaque psoriasis, the most common form of the disease, affects approximately 6 million Americans and is characterized by lesions topped with silvery white scales (National Psoriasis Foundation , 2007). The disease can be limited to a few spots or involve extensive areas of the body. It appears most commonly on the scalp, knees, elbows, and trunk.
Psoriasis is often misperceived as a cosmetic disease. At Central Dermatology, we view psoriasis as being equal or greater to heart disease or cancer in its impact on a patient’s life. It is a chronic and serious condition that must be monitored and managed continuously.
The objective of this manuscript is to address psoriasis involving the hands and feet, and how this particular form of the disease is not only more challenging to treat but also causes serious physical, quality of life, and self-image problems, even in patients whose disease has largely been cleared from the rest of their body surface area (BSA).
Psoriasis involving the hands and feet affects only about 30% of patients with plaque psoriasis, but is a uniquely problematic form of the disease (Fretzin, Crowley, Jones, Young, & Sobell, 2006). The impact of hand and foot psoriasis on patients’ quality of life is extremely high. While these individuals may have a relatively small BSA involved, the location of the lesions often prevents patients from participating in everyday activities and the visibility of the disease weighs heavily on emotions and self-image. Unlike many other forms of this disease, hand and foot psoriasis is difficult to treat and often refractory to multiple therapies, even those that are effective in generalized psoriasis. Patients with hand and foot involvement are affected to a greater degree by physical aspects of the disease (such as pain, discomfort, cracking and bleeding of the skin) than patients without lesions on the hands and feet (Pettey, Balkrishnan, Rapp, Fleischer, & Feldman, 2003). While modest success has been achieved with most conventional treatments (such as phototherapy), the toll that hand and foot involvement can take on a patient physically, psychosocially, and even economically requires that the bar for treatment success be raised when treating this specific subpopulation.
Psoriasis of the palms and soles
What is psoriasis?
Psoriasis is a chronic inflammatory skin disease in which there are clearly defined, red, scaly plaques (thickened skin). There are various subtypes of psoriasis.
Psoriasis is linked to other health conditions, including inflammatory arthritis, inflammatory bowel disease (especially Crohn disease), uveitis and celiac disease.
How does psoriasis affect the palms and soles?
Psoriasis may be localised to the palms and soles or part of generalised chronic plaque psoriasis. Two common patterns are observed:
- Well-circumscribed, red, scaly, plaques similar to psoriasis elsewhere
- Patchy or generalised thickening and scaling of the entire surface of palms and/or soles without redness (an acquired keratoderma)
More images of palmoplantar psoriasis …
Palmoplantar pustulosis and the rare acrodermatitis continua of Hallopeau (acral pustulosis), in which yellow-brown pustules occur, are no longer classified as psoriasis. However, the conditions are associated. About 10–25% of people with palmoplantar pustulosis also have chronic plaque psoriasis.
Clinical features of palmoplantar psoriasis
Palms and soles affected by psoriasis tend to be partially or completely red, dry and thickened, often with deep painful cracks (fissures). The skin changes tend to have a sharp border and are often symmetrical, ie similar distribution on both palms and/or both soles. At times, palmar psoriasis can be quite hard to differentiate from hand dermatitis and other forms of acquired keratoderma. Plantar psoriasis may sometimes be similar in appearance to tinea pedis. There may be signs of psoriasis elsewhere.
Palmoplantar psoriasis tends to be a chronic condition, ie, it is very persistent.
Compared to chronic plaque psoriasis on other sites, palmoplantar psoriasis is more commonly associated with:
- Psoriatic nail dystrophy
- Psoriatic arthritis
What causes palmoplantar psoriasis?
The tendency to psoriasis is inherited, but what causes it to localise on the palms and soles is unknown. It may be triggered by an injury to the skin, an infection, or another skin condition such as hand dermatitis. It may first occur during a period of psychosocial stress. Certain medications, particularly lithium, may be associated with the onset of flares of psoriasis.
Psoriasis is more common, often more severe, and sometimes difficult to treat in patients that are obese, have metabolic syndrome, that drink excessive alcohol or smoke tobacco.
How is the diagnosis of palmoplantar psoriasis made?
Palmoplantar psoriasis is diagnosed by its clinical appearance, supported by finding chronic plaque psoriasis in other sites. Mycology of skin scrapings may be performed to exclude fungal infection. Skin biopsy is rarely needed.
What is the treatment for palmoplantar psoriasis?
Improvement in general health can lead to improvement in palmoplantar psoriasis.
- Weight loss, if overweight
- Regular exercise
- Stress management
- Minimum alcohol
- Smoking cessation
- Investigation and management of associated health conditions
Mild psoriasis of the palms and soles may be treated with topical treatments:
- Emollients: thick, greasy barrier creams applied thinly and frequently to moisturise the dry, scaly skin and help prevent painful cracking.
- Keratolytic agents such as urea or salicylic acid to thin down the thick scaling skin. Several companies market effective heel balms containing these and other agents.
- Coal tar: to improve the scale and inflammation. Because of the mess, coal tar is often applied at night under cotton gloves or socks.
- Topical steroids: ultrapotent ointment applied initially daily for two to four weeks, if necessary under occlusion, to reduce inflammation, itch and scaling. Maintenance use should be confined to 2 days each week (weekend pulses) to avoid thinning the skin and causing psoriasis to become more extensive.
Calcipotriol ointment is not very successful for palmoplantar psoriasis. It may also cause an irritant contact dermatitis on the face if a treated area inadvertently touches it. Dithranol is too messy and irritating for routine use on hands and feet.
More severe palmoplantar psoriasis usually requires phototherapy or systemic agents, most often:
- Bathwater PUVA
Biologics (targeted therapies) are also sometimes prescribed for severe palmoplantar psoriasis. However, it should be noted that TNF-alpha inhibitors such as infliximab and adalimumab may trigger palmoplantar pustulosis.
This author details the diagnosis and management of a patient who presented with severe cracks and fissures on both heels. An anxious middle-aged caregiver presented to the clinic complaining of very painful heels. Her limping was not due to the typical heel spur syndrome we see. She had severe cracks and fissures on both of her heels. Her soles had gradually become thicker over the last six months and felt hot and painful to the touch. She was the primary caregiver for her disabled spouse and seriously ill son. She was unaware of any other family members with a similar condition and had tried cocoa butter and abrasive instruments to reduce the hyperkeratosis. Several deep painful cracks had developed in recent weeks. She denied any significant past medical history. The patient had a height of 5’2” and weighed 140 lbs for a body mass index (BMI) of 25.63 kg/m2. She was a former smoker and denied taking any medication other than vitamins A and D, magnesium and calcium at simple supplement dosages. Remarkably, the soles were quite warm at 97°F. Sole temperatures can vary individually but generally range between 75 and 80°F when one measures this with an infrared thermometer. The general examination of the skin revealed opaque, yellow-to-white plaques on the palms and knees as well as the soles. The arms and scalp were otherwise clear. The weightbearing plaques were quite thick with multiple deep fissures that tended to spare the arches and sulci. The toenails were dystrophic and thickened with subungual hyperkeratosis while the fingernails exhibited transverse onycholysis with several longitudinal spikes and superficial pits. Dermoscopic examination of the right knee plaque found red dots on a homogenous pink background with white scales consistent with psoriasis. I stained the sole scrapings with chlorazol black E, potassium hydroxide and a dimethylsulfoxide fungal stain. The examination of these scrapings under a light microscope failed to detect segmented branching hyphae. I collected nail clippings and sent them to pathology for examination with periodic acid Schiff and Gomori’s methenamine silver stains. This subsequently revealed hyphae within the nail plate consistent with a dermatophyte infection.
Arriving At The Differential Diagnosis
In order to make a differential diagnosis, it is useful to organize our thinking into four areas. What is our first impression, a mimicking condition, the worst case scenario and finally, one esoteric disease?In this case, considering the opaque keratin, palmar plantar hyperkeratosis and significant stress history, psoriasis was the first impression. A mimicking condition might be atopic eczema but the history and distribution fail to support that diagnosis. The worst case scenario could be a paraneoplastic disorder like Bazex syndrome, which is an erythrosquamous eruption of the fingers and toes associated with lung cancer. Hopefully, a good review of systems would help to rule this out. Finally, the rare differential condition could be arsenical keratosis of the palms and soles. One could investigate this differential diagnosis by exploring the patient’s travel history and possible exposure to well water contaminated with arsenic. In these cases, laboratory investigation could reveal hemolysis or electrolyte disturbances.
A Guide To Initial Treatment
The initial management should focus on symptom relief and the most likely scenario of psoriasis pending results of the workup of the differential diagnosis. For this patient, the painful, deep fissures limiting walking were the primary issue and initial treatment in the office consisted of lidocaine ointment to allow debridement and flattening of the vertical edges of the sole splits with a wetting agent and tissue nippers. In order to relieve the weightbearing pain, I applied loose Unna paste gauze dressings to the feet for 48 hours. At home, the patient applied triamcinolone 0.5% ointment twice daily followed by urea 40% cream at night. Once the fissures healed and the plaques thinned, the concurrent onychomycosis had cleared with an 84-day course of oral terbinafine (Lamisil, Novartis).The clinical diagnosis of psoriasis relies on searching for the essential disease characteristics. Most hyperkeratosis of the soles, which is due to excessive intermittent pressure as in tylomas, corns and calluses, is relatively clear and translucent while psoriatic hyperkeratosis is commonly opaque and white to yellow. Accelerated psoriatic keratinization produces the opaque hyperkeratosis of psoriasis. Accumulated immature keratinocytes retain their nuclei and therefore are not translucent like the more mature keratin of pressure keratoses. The prevalence of onychomycosis is actually higher in patients with psoriasis. Eighteen percent of patients with lower extremity psoriasis have concurrent onychomycosis.1 When it comes to moderate to severe onychomycosis, oral terbinafine is the drug of choice with long-term topical antifungal prophylaxis against re-infection. Another symptom of plantar psoriasis is increased sole temperature. Although there is no single normal foot temperature, sole temperatures do vary within a daily circadian rhythm between morning vasodilation and a cooler vasoconstricted state. Clinical examination usually occurs in a cool examination room when anxious patients exhibit moist and cool feet. Increased sole temperature can be a sign of diabetic neuropathy.2 A typical sole temperature is about 75°F while this patient’s sole measured 95°F. Plantar psoriasis may present with significant vasodilation and palpable heat along with the typical erythematous plaques.
As far as the dermoscopy examination goes, Lallas and colleagues studied 83 patients with psoriasis and 86 patients with dermatitis, lichen planus or pityriasis rubra.3 The authors found dotted vessels in a regular arrangement over a light red background and white scales to be highly predictive of psoriasis. Dermatitis patients more commonly showed yellow scales and dotted vessels in a patchy arrangement. Pityriasis rubra was characterized by a yellowish background, dotted vessels and peripheral scales while whitish lines (Wickham striae) were visible exclusively in patients with lichen planus.4
Pertinent Insights On The Primary Management Of Plantar Psoriasis
In the Manual of Dermatologic Therapeutics, Hsu discusses the various approaches to plantar psoriasis management.5 Traditional treatments include salicylic acid, corticosteroids and tars. Salicylic acid and urea are keratolytic in higher concentrations, serving not only to thin the hyperkeratotic plaques by keratolysis but also to facilitate the penetration of topical medications. Topical corticosteroids have three useful mechanisms of action. First, they are potent cutaneous vasoconstrictors that slow epidermal proliferation. Secondly, they are strong immune blockers of this T-cell mediated disease. Finally, corticosteroids are anti-inflammatory by slowing lymphocyte and cytokine mediators. Initially, patients can use a class I steroid like halobetasol (Ultravate) for a maximum of two weeks with a class III mid-potency ointment such as triamcinolone (Kenalog, Bristol-Myers Squibb)after initial improvement. Hydration of the skin before application increases corticosteroid absorption fivefold while plastic wrap occlusion increases hydration 40 percent and increases corticosteroid efficacy up to 100-fold.5 The optimal frequency of application is two to three times per day. Patients can significantly reduce the risk of adverse drug reactions such as tachyphylaxis, atrophy and striae by suspending applications one day per week.5 Patients should avoid systemic steroids because a severe rebound reaction often occurs upon cessation.Coal tars inhibit DNA synthesis. Coal tar 5% applications transiently trigger hyperplasia but after 40 days of application reduce epidermal thickness by 20 percent.5 Salicylic acid ointment or gels are keratolytic at 3 to 6% concentrations. They help thin the hyperkeratotic plaques by solubilizing intercellular cement and enhancing desquamation. Urea compounds have a softening and hydrating effect at lower concentrations, and are keratolytic at higher concentrations. They work by disrupting hydrogen bonds within epidermal proteins. Calcipotriene is a vitamin D3 analogue that induces terminal epidermal differentiation and inhibits keratinocytes production. The efficacy of calcipotriene matches class II topical steroids without their adverse effects.5 It is useful to remember that combinations of these agents can synergistically potentiate each other’s actions. Some effective products exploit this effect by combining calcipotriene (Dovonex, Warner Chilcott) with a potent corticosteroid. Phototherapy combining oral retinoids with PUVA or UVB administered with special light boxes for the soles and palms can be effective. Psoriasis typically follows a chronic and recurrent course. Patients with generalized involvement are best served by dermatology consultation. In addition to phototherapy, dermatologists can employ oral immunosuppressive therapies like acitretin (Soriatane, Stiefel Laboratories), methotrexate (Trexall) and cyclosporines. Methotrexate with folic acid supplementation can clear many cases of palm and sole psoriasis within four to six weeks.A topical retinoid, tazarotene (Tazorac, Allergan), modulates differentiation and proliferation of epithelial tissue, and perhaps has anti-inflammatory and immunomodulatory activities. There are several protocols but the least irritating is to apply the medication for 15 to 20 minutes and then wash it off. Topical retinoids are effective but childbearing females must avoid them because the retinoids are teratogenic and carry a class X warning.6 New biologic therapies like etanercept (Enbrel, Amgen) and tumor necrosis factors are available for severe unresponsive psoriasis and may be tertiary care choices. Richetta and coworkers found that adalimumab (Humira, AbbVie) for 12 weeks was safe and efficacious in an open-label clinical trial of patients with palmoplantar psoriasis.7
Strategies To Avoid Exacerbating Psoriasis
It is widely accepted that psychosocial stress can trigger exacerbations of psoriasis so one should consider stress reduction exercise and behavioral counseling recommendations.8 Even in patients with mild psoriasis, there is a significant increase in the risk of myocardial infarction and stroke from this chronic inflammatory disease so internal medicine consultation is also appropriate.9,10 Patients should be aware of the recurring course of psoriasis with its periods of improvement followed by acute flares. It is also important to screen for underlying inflammatory arthritis with foot radiographs.11 Dr. Bodman is an Associate Professor at the Kent State University College of Podiatric Medicine. He is a Diplomate of the American Board of Podiatric Medicine. Dr. Bodman is in private practice in Ohio. References 1. Klaassen KM, Dulak MG, van de Kerkhof PC, Pasch MC. The prevalence of onychomycosis in psoriatic patients: a systematic review. J Eur Acad Dermatol Venereol. 2013 Aug 19, epub ahead of print. 2. Houghton VJ, Bower VM, Chant DC. Is an increase in skin temperature predictive of neuropathic foot ulceration in people with diabetes? A systematic review and meta-analysis. J Foot Ankle Res. 2013; 6(1):31. 3. Lallas A, Kyrgidis A, Tzellos TG, Apalla Z, Karakyriou E, Karatolias A, Lefaki I, Sotiriou E, Ioannides D, Argenziano G, Zalaudek I. Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea. Br J Dermatol. 2012; 166(6):1198-205. 4. Micali G, Lacarrubba F, Massimino D, Schwartz RA. Dermatoscopy: alternative uses in daily clinical practice. J Am Acad Dermatol. 2011; 64(6):1135-46. 5. Hsu SP. Formulary. In (Arndt A, Hsu J, eds.) Manual of Dermatologic Therapeutics, seventh edition, Lippincott Williams & Wilkins, Philadelphia, 2007, chapter 40, pp. 315-318. 6. Mehta BH, Amladi ST. Evaluation of topical 0.1% tazarotene cream in the treatment of palmoplantar psoriasis: an observer-blinded randomized controlled study. Indian J Dermatol. 2011; 56(1):40-3. 7. Richetta AG, Mattozzi C, Giancristoforo S, D’Epiro S, Cantisani C, Macaluso L, Salvi M, Calvieri S. Safety and efficacy of Adalimumab in the treatment of moderate to severe palmo-plantar psoriasis: an open label study. Clin Ter. 2012; 163(2):e61-6. 8. Hunter HJ, Griffiths CE, Kleyn CE. Does psychosocial stress play a role in the exacerbation of psoriasis? Br J Dermatol. 2013; 169(5):965-74. 9. Armstrong EJ, Harskamp CT, Armstrong AW. Psoriasis and major adverse cardiovascular events: a systematic review and meta-analysis of observational studies. J Am Heart Assoc. 2013; 2(2):e000062. 10. Biyik I, Narin A, Bozok MA, Ergene O. Echocardiographic and clinical abnormalities in patients with psoriasis. J Int Med Res. 2006; 34(6):632-9. 11. Lowell DL, Osher LS, Grady AF. Incidental findings of massive heel spurs in a veteran with a variant of psoriatic arthritis. J Am Podiatr Med Assoc. 2012; 102(5):422-7.
Is That Rash Psoriasis, or Is It Something Else?
Psoriasis is a chronic condition thought to be caused by an immune system dysfunction. If you have psoriasis, your immune system sends signals to your skin that speed up the production of skin cells. While there are signs and symptoms that set the disease apart from other conditions affecting the skin, it isn’t always easy to distinguish it at first.
About 7.5 million people in the United States have psoriasis, which causes itchy, scaly plaques of thick, red, dry skin. Psoriasis plaques can consist of a few spots of dandruff-like scales or major eruptions that cover large areas. While the disease can affect any part of your body, it most often surfaces on the scalp, elbows, knees, back, face, palms, and feet.
There are five types of psoriasis (plaque psoriasis, guttate psoriasis, pustular psoriasis, inverse psoriasis, and erythrodermic psoriasis), none of which is contagious. Each type causes a different skin rash and can appear on different areas of the body. Plaque psoriasis, also known as psoriasis vulgaris, is the most common type. As many as 90 percent of people with psoriasis have this form. Guttate psoriasis is the second most common type. Far less common are pustular psoriasis, which is characterized by pus-filled bumps known as pustules, and erythrodermic psoriasis, a very serious form of the disease that affects about 3 percent of people with psoriasis.
It’s unclear what exactly causes psoriasis, though genetic factors have a lot to do with whether you’ll develop the condition.
Psoriasis typically responds to treatment. Most psoriasis therapies aim to stop skin cells from growing so quickly and to smooth out the skin. But the disease may never go away completely, and it tends to come back. Treatment options include topicals and biologic drugs. Another option is light therapy, or phototherapy, in which targeted light rays are delivered to the skin.
Because psoriasis can look like other skin conditions that cause itchy, scaly rashes with inflammation, it is often confused with various disorders. These may include common skin conditions such as acne, eczema, or heat rash. Psoriasis can also resemble and be confused with the fungal infection known as ringworm.
Most of the time, psoriasis can be diagnosed with a physical examination. However, a skin biopsy may be needed to rule out other possibilities and arrive at a definitive diagnosis.
Do you know how to spot signs of psoriasis? Here are some things you can look out for.
(The images that follow are of real medical conditions and may, in some cases, be graphic.)
When psoriatic disease strikes the hands and feet
Gary Bixby, who lost all his fingernails and toenails to severe psoriasis (but is otherwise fit at 73), says psoriatic nail disease makes it painful to chop fuel for his wood-burning stove, a frustrating problem during winters at his home in Blair, Wisconsin.
“It’s hard to do anything without fingernails, and if I use my fingers too much, they bleed,” says Bixby, who developed psoriasis two years ago. The disease appeared first as pitting in two fingernails and a few scales of plaque psoriasis on his left foot. His primary care provider didn’t recognize it as psoriasis, and the disease went undiagnosed until it rapidly got worse.
“It was affecting more fingernails, then my toenails and large areas on my arms, legs and trunk,” says Bixby. “That’s when I went to a podiatrist, who thought I had psoriasis, and then then to a dermatologist, who confirmed it.”
To get an idea of the impact of psoriatic disease on the hands and feet, think of the pain of a hangnail on a finger or a blister on a foot, and how much these small injuries consume your attention and interfere with daily tasks, says Kristina Callis Duffin, M.D., co-chair of the department of dermatology at the University of Utah in Salt Lake City.
“Having psoriasis or psoriatic arthritis on the hands and feet is life-altering,” she says. “It raises the bar for how much it affects your quality of life.”
Duffin was the lead investigator for a study comparing people who have psoriasis on the palms of the hands and soles of the feet (called palmoplantar psoriasis) with those who have the disease elsewhere. The study, published in the September 2018 Journal of the American Academy of Dermatology, found that those with hand and foot involvement were almost twice as likely to report problems with mobility and almost two-and-a-half times more likely to say they had trouble completing usual activities.
“Those with palmoplantar psoriasis scored much worse on multiple quality-of-life measures, even though they typically had less total affected body surface area,” says Duffin, who is also an NPF medical board member.
Body surface area is one way dermatologists measure psoriasis severity and decide how aggressively to treat it. But it’s not the best tool for making treatment decisions when the hands or feet are affected, Duffin says. “In those cases, we often start treatment with a biologic even when the total involved body surface area is relatively small.”
PsA also hits especially hard when it affects hands and feet.
“If joints in the hands and feet are hurting and swollen, it can affect every aspect of their function,” says Alice Gottlieb, M.D., Ph.D., clinical professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City and an NPF medical board member.
Types, symptoms and treatment
Like psoriasis and PsA elsewhere on the body, psoriatic disease in the hands and feet can cause itchy, scaling, reddened skin plaques and painful, swollen joints. Specific types and symptoms of hand and foot psoriasis and PsA, however, can also cause less-familiar skin and joint issues.
Palmoplantar psoriasis, plaque psoriasis on the feet or hands, affects about 40 percent of people with plaque psoriasis, who often don’t have much skin disease elsewhere. As noted, its substantial effects on function and quality of life mean dermatologists typically use advanced medications to control symptoms. Treating certain types of palmoplantar psoriasis is still challenging, despite the rapidly expanding list of medications for psoriasis and PsA. Often, palmoplantar psoriasis doesn’t respond as well to treatment as does psoriasis on other parts of the body.
Most biologics, which work by targeting specific proteins that turn up inflammation in psoriatic disease, such as tumor necrosis factor (TNF) or interleukin-17 (IL-17), have some effect on certain people with palmoplantar psoriasis.
No one treatment works for everyone, and people with palmoplantar psoriasis may have to try several medications or combinations of treatments to relieve symptoms. Gary Bixby, for example, didn’t get better with either a TNF or an IL-17 inhibitor. The third biologic he tried blocks another interleukin protein, IL-23, and, three months after his first injection, he’s getting better results.
“I’m seeing improvements in my fingernails and the plaques on my body, which I didn’t get with the first two biologics. I’m cautiously hopeful,” he says.
Palmoplantar pustular disease, or pustulosis, affects about 5 percent of people with psoriasis. It shows up as small, pus-filled blisters on reddened, tender skin. It can also cause painful cracking
Biologics can sometimes make pustular disease worse, says Duffin, so dermatologists may decide to begin treatment with a traditional disease-modifying antirheumatic drug (DMARD) such as methotrexate or cyclosporine.
“There are also new medications in development, specifically anti-IL-36 biologics, that could be a good treatment pathway for pustular psoriasis,” says Duffin.
Psoriatic nail disease can cause a host of symptoms in both the nail bed and the matrix, the area where fingernails and toenails start their growth. These include pitting, crumbling, thickening, discoloration, white or reddish spots, and separation of the nail from the nail bed (called onycholysis). None of these symptoms is specific to nail psoriasis, however, and some people have both nail psoriasis and nail fungus.
All this can make nail disease difficult to diagnose, says Duffin.
“If you have pitting, for example, you could have vitiligo or eczema instead of psoriasis,” she explains. (Vitiligo is a disease that causes skin, or sometimes hair, to lose its natural color.) “Sometimes, psoriasis patients are concerned about normal nail features, such as ridging or brittleness, that aren’t psoriasis.”
When the cause of nail symptoms isn’t clear, dermatologists look for signs of psoriasis elsewhere on the body. They may also look at a nail clipping under a microscope to distinguish one condition from another.
Once dermatologists understand what’s going on in the nails, they can decide how best to treat them. “All biologics have some data showing they can work better for nails than traditional DMARDs, but there is still no one slam-dunk treatment,” says Duffin, who notes that it can take months to learn whether a treatment is improving nail symptoms.
“It takes three to six months for nail to regrow entirely, so patients need to be on a treatment continuously for that time for us to know whether it’s working,” she says.
Nail psoriasis is also a risk factor for PsA, and when it occurs with other symptoms, may prompt a referral to a rheumatologist, who can evaluate you for joint disease.
Dactylitis, sometimes called “sausage” fingers or toes, is the painful swelling of digits that can occur with PsA. “When people have dactylitis, all the structure of the digits are inflamed, and this means every aspect of their function is impaired,” says Gottlieb.
Enthesitis, the swelling of the entheses, the connective tissue that joins ligaments and tendons to bone, can cause discomfort in the hands and feet of people with PsA. The sole of the foot and the back of the heel, where the Achilles tendon inserts into the heel bone, are common sites for enthesitis.
Treating PsA with appropriate medications, typically a DMARD or a biologic, should also relieve symptoms of dactylitis and enthesitis, Gottlieb says.
Researchers are now focusing more on hand and foot symptoms in clinical trials. That means physicians are getting better data about what works for specific symptoms, says Gottlieb, who is triple board-certified in dermatology, rheumatology and internal medicine.
TLC for hands and feet
Avoiding injuries, even small ones (often called microtraumas), makes good sense for people with psoriasis or PsA affecting the hands and feet.
“The Koebner phenomenon is the flaring of psoriasis in response to injury. Even minor trauma can cause a flare,” says Duffin. “For example, if you use your nails to pry open a lid, you’re probably going to make your nail psoriasis worse.”
Similarly, shoving feet into shoes without enough room to wiggle toes or wearing high heels means you’re putting constant pressure on nails and joints, which can increase pain and nail problems.
“I generally recommend flats that have good cushioning and arch support that takes the weight off toe joints – which doesn’t mean wearing ballet slippers that have no padding in the bottom,” says Gottlieb.
“You don’t want a triangle profile that squeezes the toes, because that elicits pain.” She also cautions that flip-flops, a summer favorite, expose toes and feet to trauma.
A consultation with a podiatrist, who can advise on the right footwear and design an orthotic for individual foot issues, is often helpful for people with PsA that affects the feet, Gottlieb says.
Photo: Aaron Coury
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