Overall, the way psoriasis develops is unpredictable, alternating between flares and more or less complete remissions. Everything takes place as if, under certain conditions - probably genetically determined for many patients, external events were capable of triggering outbreaks or facilitating remissions. These events vary from one sufferer to another, and it seems particularly important for each sufferer, with the help of his or her dermatologist and GP, to try to identify the factors responsible for flares or favourable to remissions. This self-observation will allow sufferers to manage their illness with increasing success and to greatly enhance the effectiveness of treatment.
A number of trigger factors have been identified:
- the skin traumas responsible for the phenomenon described by Köebner are the most familiar. Köebner’s phenomenon is chiefly observed in subjects undergoing a flare, but also in patients whose disorder started early in life and who present frequent relapses. Köebner’s phenomenon is observed in 38 to 76% of patients, according to studies. Psoriasis plaque appears one to two weeks after the triggering trauma (photos 44 and 45). The traumas concerned are extremely varied. Mechanical traumas spring firstly to mind (photo 46), of course, but any cutaneous inflammation connected with external agents or pathological events can bring upon a Köebner’s response. Therefore, one needs to look for evidence of contact eczema, of secondary skin infection, of lichen planus, of toxidermia or of scabies. Interestingly, psoriasis appears sometimes on a vitiligo patch, and there is no knowing of which direction Köebner’s phenomenon is working in: is the psoriasis promoting the vitiligo patch or vice versa? At experimental level, the majority of skin traumas can bring upon a Köebner’s response, but in order to observe this phenomenon, an epidermal and dermal wound usually has to be induced. It is noteworthy, however, that a psoriatic patch can be induced to appear after a suction or cantharidin blister is produced and the blister’s roof is removed.
- Infections, especially streptococcal sore throat, are a classic trigger for psoriasis and, particularly in children, for guttate psoriasis. The classic notion according to which eruptive guttate psoriasis disappears more easily is currently being questioned. On the contrary, it would seem that psoriasis that starts during infancy is often more progressive and more resistant to treatment.
- Endocrine factors can influence psoriasis, and more frequent attacks are observed at puberty and menopause. Psoriasis remains unmodified by pregnancy in 40% of female patients; in others, it may be improved or exacerbated, without being reproducible from one pregnancy to another in the same patient.
- The sun, and particularly sunshine coupled with sea baths have a favourable influence on psoriasis in 70% of patients. [|The effect of salt water
alone is very small.|auteur193] The two have no effect in 20%. They can aggravate psoriasis in 10% of patients.
- Excess alcohol consumption is significantly linked with the occurrence of psoriasis. It is not known whether alcohol is directly to blame for eruptions or if such drinking is associated to a decrease in therapeutic compliance. It is certain that alcohol abuse lessens the efficacy of systemic treatments, probably by altering the metabolism of these drugs: psoralens, retinoids, methotrexate (whose toxicity it also increases) and probably cyclosporine. It is important to explain to patients that it is impossible to keep control of their psoriasis if they are incapable of keeping control of their alcohol consumption.
- The emotions have long been recognized as being able to trigger a psoriasis attack. A major emotion shortly before the first psoriasis attack is found in 46 to 80% of patients, according to studies. The psoriasis flare occurs between a fortnight and several months after the emotional trigger. The emotions are often connected with an acute or chronic attack in the areas in which any individual expresses himself (affective, professional, intellectual, artistic...). The patient is often someone who keeps his emotions under excessively tight rein or gives them little or no airing. The whole thing takes place, then, as if the patient was expressing some pent-up sensitivity through the skin, due to a particular genetic condition. It is very important to explore this avenue with the patient, because if this correlation is confirmed, any technique that allows him to give free rein to his emotions will make treatment more effective, making easier to keep the illness under control on the long run and allowing some alleviation of the psychological suffering caused by the illness.
- If tracing stress and emotions is an important part of a psoriasis flare beginnings, it is equally important not to forget medication. Independently of the toxidermias, all of which can trigger Köebner’s phenomenon, some drugs may aggravate or trigger a psoriasis attack. The most well known are the beta-blockers, lithium, an abrupt halt in systemic corticotherapy. Synthetic antimalarial agents may trigger severe attacks in some patients, but this complication is rare. Non-steroidal anti-inflammatory drugs (NSAID) may favour an inflammatory attack. Less frequently, potassium iodide, progesterone, the sulphonamides and clonidine have been held responsible for these attacks. Interestingly, some attacks of the disease have been clearly linked with taking angiotensin-converting enzyme inhibitors and calcium inhibitors, thus making the treatment of hypertension difficult in psoriatic patients.
[|The role of trauma, infections, endocrine aspects, diet and excess alcohol consumption, is well discussed. A fact in psoriasis that intrigues me, and which was the subject of 2 major international meetings in 2006 and 2008 under the auspices of the International Psoriasis Council, is obesity. Why is the average weight of patients in the United States entering a clinical research study over 90 Kg? Admittedly, two thirds of these are males, but even in Europe the average weight is over 80 Kg, which appears to be higher than the non-psoriatic population. Does obesity trigger psoriasis or does psoriasis trigger obesity? Are the genetic factors triggering both? The comorbidities associated with obesity, including liver disease, diabetes, cardiac disease, have to be carefully explored in the psoriatic population as well as the increase in mortality in patients with more severe psoriasis.|auteur215]
- 2019/10/29 Focus on...World Psoriasis Day 2019
- 2019/08/12 Focus on...Latin American Clinical Practice Guidelines on the Systemic Treatment of Psoriasis
- 2019/06/03 Focus on...News from our SPIN Columbian members
- 2019/05/21 Focus on...SPIN2019 is now available on your screen!
- 2019/04/18 Focus on...SPIN Congress 2019 in Paris coming soon
News from the web office
- 2017/06/05PIN becomes SPIN - Skin Inflammation & Psoriasis International Network
- 2016/10/29PSO 2016 Congress - Webcasts Available!
- 2016/05/26PIN Survey on Phototherapy
- 2016/02/20PIN Study on Therapeutic Patient Education
- 2016/02/19World Directory of Psoriasis Medical Resources - February 2016 Update
- 2019/04/18 Focus on...SPIN Congress 2019 in Paris coming soon
- 2018/07/16SPIN Symposium at the Spring continental meeting - Tehran, 25-27 April 2018
- 2018/02/222nd National Meeting of the Egyptian Society for Psoriasis
- 2018/02/211st Psoriasis Symposium - Sarajevo 2017
- 2017/06/2815th São Paulo Meeting of Psoriasis and Vitiligo
News from medical groups
- 2018/04/183rd Turkish National Psoriasis Symposium
- 2017/06/21Brazilian Center for Psoriasis Studies joins SPIN!
- 2017/06/21Costa Rica Psoriasis Group - Meet them!
- 2017/02/02Works of the 1st Senegalese Psoriasis Day published!
- 2016/07/29Swiss S1 Guidelines for Systemic treatment of psoriasis vulgaris
News from patients associations
- 2017/02/08France Psoriasis - 2016 World Psoriasis Day
- 2016/05/26Senegal Patients Association joins PIN!
- 2015/08/04Epidermia Greece: a new partner association of PIN
- 2015/08/01Canadian Association of Psoriasis Patients joins PIN!
- 2015/04/09AEPSO Argentina launches digital map to find people with psoriasis in the country
Recent publications on Psoriasis and Atopic Dermatitis
In vitro evaluation of Naltrexone HCl 1% Topical Cream in XemaTop™ for psoriasis.
Arch. Dermatol. Res.. 2020 Mar , 312, (2):145-154.
Psoriasis is a multifactorial skin disease involving abnormal cell proliferation and inflammation; an efficacious topical treatment is yet to be identified. A formulation containing 1% Naltrexone HCl in XemaTop™ base was compounded, characterized and evaluated in vitro as a possible treatment for psoriasis. A three-dimensional psoriasis tissue model was exposed to the formulation for 2 or 5 days and analyzed for the level of markers of cellular proliferation, and inflammatory cytokine IL-6. (...)see on pubmed
Hydrogen peroxide in neutrophil inflammation: Lesson from the zebrafish.
Dev. Comp. Immunol.. 2020 Apr , 105:103583.
The zebrafish has become an excellent model for the study of inflammation and immunity. Its unique advantages for in vivo imaging and gene and drug screening have allowed the visualization of dual oxidase 1 (Duox1)-derived hydrogen peroxide (HO) tissue gradients and its crosstalk with neutrophil infiltration to inflamed tissue. Thus, it has been shown that HO directly recruits neutrophils via the Src-family tyrosine kinase Lyn and indirectly by the activation of several signaling pathways (...)see on pubmed
IL-36α contributes to enhanced T helper 17 type responses in allergic rhinitis.
Cytokine. 2020 Apr , 128:154992.
T helper 17 (Th17) cell subsets, belongs to CD4+ T cell lineage, are proved to be closely related to pathophysiology of AR recently. The interleukin-36 (IL-36) had been reported to promote the up-regulation of Th17 cytokines in psoriasis. We investigated the regulation of Th17 inflammation by IL-36 family cytokines in allergic rhinitis (AR).see on pubmed
Atopic dermatitis induces anxiety- and depressive-like behaviors with concomitant neuronal adaptations in brain reward circuits in mice.
Prog. Neuropsychopharmacol. Biol. Psychiatry. 2020 Mar 02, 98:109818.
Clinically, it has been reported that atopic dermatitis (AD) has been linked with negative emotional problems such as depression and anxiety, thereby reducing the quality of life, but little is known about the molecular mechanism that underlies AD-associated emotional impairments. We sought to determine whether AD could induce anxiety- and depressive-like symptoms in mice and to identify pertinent signaling changes in brain reward circuitry. AD-like lesions were induced by the repeated (...)see on pubmed
Efficacy and safety of indigo naturalis ointment in Treating Atopic Dermatitis: A randomized clinical trial.
J Ethnopharmacol. 2020 Mar 25, 250:112477.
Indigo naturalis, a herbal medicine with a history of use dating back to ancient times, may be a good alternative topical treatment for atopic dermatitis (AD).see on pubmed
"Eczema" of the nape: A marker of pthiriasis capitis.
Parasitol. Int.. 2020 Apr , 75:102026.
Pthirus pubis usually infests the pubis, inguinal folds, buttocks and perianal region. In hairy males or when the infestation is longstanding, this louse can also occur on the thighs, abdomen, chest, axillae and beard. Eyelashes may be involved in children. The involvement of the scalp is very rare. We describe four girls with P. pubis infestation located exclusively on the scalp which was characterized by a rash on the nape that can suggest a head and neck form of atopic (...)see on pubmed