July 15, 2024 • 26 mins
In the first episode of this two-part topic, your hosts Dr George Moncrieff and Dr Roger Henderson give you a complete guide to psoriasis, answering:
- What is psoriasis?
- Who gets psoriasis?
- Why does psoriasis occur in different groups of people?
- How is psoriasis diagnosed?
- What is the impact of psoriasis on someone’s mental wellbeing?
- What it means when doctors say ‘psoriasis is an inflammatory condition.’
- What triggers psoriasis flare-ups?
Thank you to our kind sponsor AproDerm, who provide a range of emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
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We hope you find this podcast interesting and helpful. Please leave us a review or email info@aproderm.com with any feedback on this episode or suggestions on skin-related topics that you would like to hear about in future podcasts.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Content warning (00:00):
this podcast discusses suicidal feelings, which
some listeners may find distressing.
Hello and welcome to this Skin Deeppodcast, where we look at skin-related
(00:23):
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, though I'mnow retired from my practice.
And I was the Chair of theDermatology Council for England.
Now today, George and I are going tobe talking about psoriasis, and what
(00:43):
we should know about before we look totreat it, and this is the first of two
podcasts on this very common condition,with its treatment being the subject
of the second one in two weeks time.
So do make a note to check that out.
(01:04):
But, first of all George, I do thinkit's helpful to talk about the definition
of psoriasis, because many peoplelistening might not understand very
clearly exactly what the condition is.
Psoriasis is a skindisorder which is chronic.
In other words, it goes on and on.
So if you have psoriasis, the chancesare you may come back with it at a later
(01:24):
stage in your life, even if it clears up.
But I think it's important to sayfrom the outset, it's non-infectious,
it's not contagious and it'san inflammatory skin disorder.
The skin is inflamed.
And when you look at it, youtypically have these well-defined,
red areas of abnormal skin, whichhas a very typical silvery scale.
(01:46):
The scale easily falls off, but itgets air underneath it, which means
that when you look at it, it hasthat sort of silvery look to it.
So it's a chronic, non-infectious,inflammatory skin disorder with
well-defined red plaques, is whatdoctors call them, and silvery scale.
And I think many people listening willstart to recognise that either on people
(02:07):
they've seen themselves or even from thecondition that they've got, which is maybe
one of the reasons why they're listening.
But the cause, the epidemiology, if I canuse that term, it's really interesting
as to why someone with psoriasisshould have, psoriasis, isn't it?
Well, yes, it is one of the most commonskin conditions, one of the most common
(02:28):
conditions, that our society suffers with.
So it is extremely common.
And what advantage does that have?
Why is it there?
I think this is really quite fascinating.
It's common in those societies,today, that in the past were
affected by scarlet fever.
(02:48):
Psoriasis offers some protection againstthe bacteria that causes scarlet fever,
the streptococcus, and we've justgone through a minor epidemic of that.
The streptococcus appears to becoming a little bit more, vigorous
and virulent in recent years.
But in the past it was, talking 70years ago, it was really frightening.
(03:10):
It was pre-antibiotic era, and itkilled a large number of people,
a very large number of children.
And in scarlet fever, yourskin becomes bright red.
It can peel off, and if it's reallysevere, you can then start losing a
lot of fluid, your blood volume drops.
You don't perfuse important thingslike your liver and your kidneys,
(03:33):
they start to fail, and you die.
Well you can die rather, it's a nasty,dangerous illness, scarlet fever.
And it's not as virulenttoday as it was 100 years ago.
But if you've got a tendency topsoriasis, you're relatively protected.
Instead of getting red skin andskin peeling off, you get thickening
of the skin and raising up, whatdoctors call hyperkeratosis,
(03:57):
these plaques of psoriasis.
And in particular, you get apattern we call guttate psoriasis.
From the Latin guttae, "a raindrop".
It looks like you've got little raindropsof psoriasis all over your body.
And that typically comes on a couple ofweeks after encountering a streptococcal,
a bad streptococcal infection.
So you don't die, you havean inconvenient skin rash.
(04:21):
And that confers enormous advantageto you, and that probably accounts
for why the genes persisted.
If you look today where psoriasisoccurs, it occurs in those societies
where scarlet fever killed.
So, for example, compare theNorth of China to the South.
Psoriasis today is four times morecommon in the North than the South.
Looking at their records in the19th century, scarlet fever was
(04:45):
four times more common in theNorth of China than the South.
Aborigines had no scarlet fever,they had no psoriasis until we
brought our genes into their genepool, and the same with Indians.
So, it's very, very interestinglooking at that relationship.
So psoriasis does confer someadvantages, more than that actually.
If you've got psoriasis, you harbourthe bacteria in your throat, where
(05:09):
it does you no harm, and you can thenpopulate the next epidemic of scarlet
fever, killing off your geneticcompetition; people who haven't got
the advantage of having psoriasis.
But the headline figures are,yeah, it affects roughly 2% of
the world population, and that'sabout the prevalence in the UK.
In the world, 125 million people with it.
(05:30):
It's much more common in white Americanswho migrated to America from Scandinavian
countries where scarlet fever wascommon, 4.6% in white Americans.
Less than 1% of blackAmericans have psoriasis.
And it affects men and women equally.
Although it often starts inchildhood, typically with that guttate
(05:51):
pattern following a sore throat.
Roughly a third of people firstencounter, first have their psoriasis
as a child or a young teenager.
And genetics plays a huge role.
This is a multigene condition,where polygenic, in other
words, isn't just one gene.
It may be a combination of genes.
But 40% of patients with psoriasishave a family history and the more
(06:16):
members of your family there are,with psoriasis, the more likely you
are to get psoriasis earlier, andthe more severe it's going to be.
But, there are over 60 genes, that,we wonder whether those might account
for some of the different patternsof psoriasis we sometimes see.
Yeah, so it's much more complex thanmight initially appear and you'd
think that although it is a complexcondition, you'd think diagnosing
(06:39):
it would be fairly straightforward.
In other words, you'd rock up to yourdoctor surgery, they'd take a look at
your skin patches and there you are.
But one of the things I've learntover too many years of treating
patients with psoriasis, there are ahuge range of possible presentations.
So it can make the diagnosis alittle bit trickier than people
might think so there are a numberof patterns of psoriasis out there.
(07:04):
The most common pattern, is called"chronic stable plaque psoriasis".
And that classically affects the backs ofthe elbows and the fronts of the knees.
Often on the body, on the buttocksand around the place, it can be quite
severe and cover large areas of skin,and that's probably the most common.
The scalp is very commonly affected,probably about 4 out of 5 patients
(07:27):
have involvement of their scalp andit's not necessarily visible because
hair will cover that very effectively.
But if you lift the hair up,you can see it just creeping
just beyond the hair margin.
So very, very common.
It can affect the nails.
The nails can be really troublesome,and often you just get minor changes,
like little holes drilled intothem, we call that pitting, or the
(07:50):
nail can lift off from the nailbed, which is quite unpleasant,
with a lot of scale and thickeningof the tissue underneath the nail.
People don't recognise it,often miss flexural psoriasis.
It can go for the armpits and thegroin and the buttock crease and
under the breast in these sort ofmoist areas and can be a bit tricky
(08:10):
there because it doesn't look quitethe same as psoriasis elsewhere.
It hasn't got that dry, scaly look.
It just looks glazed, sharplydemarcated as it typically is in
the plaque psoriasis but without thescale it just looks shiny and glazed
and can be often misdiagnosed there.
And then there are other patterns too.
(08:31):
But I think the important thingis if you're seeing somebody
with psoriasis is to look atthem as holistically as you can.
You need to find out abouttheir family history.
You need to think about any aggravatingfactors that might be going on that
are driving it and then you lookcarefully and you feel the plaques.
I think, as a doctor, it's so important totouch our patients, with their permission,
(08:52):
wash our hands and then touch them.
Feel their plaques, because societygenerally is repelled by skin disease
and patients with psoriasis oftenfeel quite ostracised by that.
And I think for a physician to be preparedto go straight in and feel their plaques,
examine the nature of the scale, lookingcarefully at all the nails and asking
about the flexures, feeling the scalp.
(09:14):
I think that's so important and sothat's part of my assessment there.
Of course, and you mentioned patientswith skin conditions feeling, ostracised
and this is perhaps greater thanever with people with psoriasis.
Whenever I've given talks atconferences about psoriasis and
mentioned the psychological impactof psoriasis, including some truly
(09:38):
dreadful suicide statistics in theUK of people with psoriasis killing
themselves simply because of thepsychological impact of their psoriasis.
You can usually hear a pin drop inthe room as those facts sink in.
Now, regular listeners to thispodcast will know that I don't talk
about individual patients, often.
(09:59):
But in this case, I am going tomention a particular patient.
I have changed details so they can't beidentified, and it was a long time ago.
So I'm not breaking any confidences here.
But the reason I would mention this oneis that this completely altered how I
viewed patients with psoriasis forever.
In fact, it altered how I viewed patientswith all skin conditions forever.
(10:20):
Which was a highly successfulbusinessman, single man, late thirties,
been having treatment for psoriasispretty much for over a decade.
Seen a lot of my colleagues, andeventually rocked up in front of my desk,
I think more in desperation than anything.
(10:41):
I was a senior partner in practice,and he thought that, well, I'll go
and see, you know, the senior partner.
Patients sometimes think thatbecause you're senior partner,
you know more, which is untrue,but that's a psychological fact
of what can sometimes happen.
And he sat down and we were talkingabout psoriasis and how he was wanting
to try and get to the bottom of this andthen he promptly burst into tears on me.
(11:06):
Which really took us, I think, both back.
He was a chap who tended to sort ofkeep his emotions to himself, and so
we explored that, and going throughquite a long consultation, into a
nutshell, he said that he was just,desperately, desperately lonely.
(11:28):
He could not be in a relationshipand had not been in a relationship
because of the impact of psoriasisand the shame he felt from it.
He had not had physical contact.
He had not hugged someone for yearsbecause he was ashamed about his psoriasis
and he was a single man because hecould not bear anyone seeing him in the
(11:52):
morning, hoovering the skin flakes outof his bed, and that's why he was single.
And that really dropped thescales from my eyes and I really
understood then the impact,psychologically, of skin conditions.
We fortunately managed to get hispsoriasis controlled, and better.
(12:16):
And a couple of years later I justhappened to see him in passing and he
was as happy as I've ever seen anyone,in a lovely relationship, and that
has continued through to this day.
But I think the point of that is thatfor some people with psoriasis, the
physical impact of this visible conditionabsolutely pales, compared to the impact
(12:38):
it does on their mental health, and Isuspect you've had many similar stories.
I have, but that is a very lovely andpowerful story, and I can understand
how it would change my practiceas well, for the better, I hope.
Ah, it's so easy not to hear about thedistress, somebody else is suffering.
(12:59):
Humans have that extraordinary capacityto turn a blind ear to that sort of thing.
And I think that shame, that wordshame really resonates with me.
Isn't that awful for him?
What a lovely, lovely outcome.
And I think that in this modern worldwe live in, skin disease is something
(13:20):
that people are repelled by, andparticularly with young people who
are using social media, where how theylook is being noticed and commented
on and criticised is so powerful.
I think we need to bevery, very alert to this.
Because skin diseases are visible.
It's often the first thingsomeone notices when they see you.
(13:44):
And we're wired to be repelled byphysical deformities, and patients
experience that all day, every day.
So it's no surprise that skindiseases punch way above the
objective severity when it comes tothe impact on their life experience.
A study about 5 years ago showed that morethan 4 out of 5 patients with psoriasis
(14:06):
reported that they had experienceddiscrimination or humiliation because
of their psoriasis, and almost a halfreported it had adversely affected
their personal relationships, especiallyintimate, as in your patient's case.
So I think it's something weneed to be very, very alert to.
Nowadays, we're increasingly talkingabout what we call the cumulative
(14:29):
life course impairment, that adisease like psoriasis can cause.
You can imagine how some loss ofself-esteem because of your psoriasis
and loss of confidence as a teenagercan mean that you decide not to
try to join a team or even remainin school to do your A-levels.
And then underachievement at schoolmeans you underachieve after school.
(14:52):
You don't get the furthereducation opportunities.
Career options are limited and missed.
And it has an increasing potentialimpact on relationships, which you
may never want to embark on, likeyour man, or you do and they fail.
And the consequences of what might to manyjust seem as a trivial skin condition, a
bit of scale on the backs of your elbowsand the fronts of your knees, can progress
(15:16):
to have a devastating and lifelong impact.
And I think we need to really wake upto that and recognise that this matters.
Yes, I cringe when I hear people say,"you've got a touch of psoriasis."
It's like saying "you'rea little bit pregnant."
It's, you know, irrespective ofthe severity of the psoriasis,
(15:39):
and this has been replicated in anumber of studies looking at other
conditions like eczema and acne.
There is no direct link between howsevere the skin condition is and how
severe the psychological impacts.
You can have a relatively mildskin disease and absolutely
enormous, psychological impacts.
(16:01):
There is something that youjust mentioned earlier and I
just wanted to pick up on it.
You said that psoriasis is an inflammatorycondition, which might be an interesting
statement to some people listening.
Why did you make that point?
Well, I stressed it, didn't I?
Yeah.
Chronic inflammation from whatever'sdriving it, whether it's arthritis
(16:23):
or psoriasis, or even eczema.
We now know even badeczema, is bad for you.
And it's particularlybad for our arteries.
It causes hardening of the arteries.
So, it accelerates the rateat which that gets worse.
So controlling inflammation, werecognise now, is so important.
You cannot leave chronic lowgrade background inflammation.
(16:45):
It will increase your riskof heart attacks and strokes.
Psoriasis is also associated with centralobesity, that's sort of fat tummies.
And that's linked to acceleratedheart disease and diabetes.
And, in fact, psoriasis is alsoassociated with an increased risk
of diabetes and the condition of theliver where you get fat deposits in the
(17:06):
liver causing it to not work so well.
So, non-alcoholic fatty liver diseaseand diabetes are other concerns.
These are very, very important for GPsand I think that if you have moderate
or severe psoriasis, I think it'sworth talking to your doctor about
your overall risk for heart diseaseand asking if they can do what's called
(17:27):
a QRISK, which is putting togetheryour blood pressure, your cholesterol,
whether you smoke or not, and so on.
Putting all those together to givesome sort of measure of how high
your risk is for heart disease.
And taking that into the context ofsomeone with chronic inflammation, it
means that you might address some ofthose risk factors more aggressively.
(17:50):
Yeah.
Inflammation really matters.
Yeah.
I think anyone who's listening withpsoriasis, will know from experience just
how quickly their psoriasis can go fromwell-controlled to a significant flare.
Almost to the point of being out ofcontrol when certain factors trigger
(18:11):
it, almost like petrol on a fire.
So I sometimes say that, you know,well-controlled psoriasis hasn't
gone away; it's just there likeembers of a fire and then certain
things can throw petrol on it.
So I often think of the four S's whenI'm looking at patients with psoriasis.
There's potential triggers,although there are lots more,
and you probably mentioned them.
But things like, as you say,streptococcal infection, smoking,
(18:34):
absolute, and we'll touch on this,a big no no, stress, and steroids.
And those are my four.
I always sort of go down thelist first, although there
are some more on top of that.
I love those four S's.
It's so helpful, isn't it?
Yep, so streptococcal infections.
And interestingly, I mentionedthat patients with psoriasis often
harbour that bacteria in their throatand they have more sore throats.
(18:57):
But the strep can be a sort of chronicsort of stimulus for more psoriasis.
People have tried penicillin to try anderadicate it, but it doesn't seem to help.
So that's not the answer.
But there's certainly that link.
Yeah, smoking.
Smoking does make psoriasis worse.
But also, like psoriasis,it hardens the arteries.
(19:20):
So you've got a double whammythere, really bad news.
And it's also the driver for a very,very nasty, though not uncommon,
fairly uncommon rather, pustularcondition that occurs on the hands,
or feet; can be very disabling.
I haven't seen that insomeone who's never smoked.
So, an important message.
If you've got psoriasis,you shouldn't be smoking.
(19:41):
Absolutely not.
Stress, well we've alreadycovered the fact that psoriasis
is stressful, but stress seemsto make psoriasis worse as well.
So you're into a vicious cycle there.
The worse your psoriasis, the morestressed you're going to feel, the
more stressed you're going to feel,the more, it's going to be making
the psoriasis worse and so on.
So, not necessarily easy toaddress that but certainly being
(20:03):
alert to the stresses in your lifeand see what you can do there.
Steroids, I don't like usingsteroids on their own, on the
skin, in patients with psoriasis.
I think that if I ever prescribe a steroidtopically, for psoriasis, I'd want to
use another agent to go alongside it.
Because that can, particularly whenyou stop, withdraw the steroid,
(20:24):
it can trigger a severe flare.
And I've even seen terrible flaresof psoriasis when people have been
on steroids for something else.
Acute asthma, or whatever, andthey've been on a steroid, is when
you stop the steroid, things cansuddenly go dramatically and very
severely out of control, rarelyputting the patient on intensive care.
(20:44):
So I personally say don't use topicalsteroids on their own for psoriasis
There are a lot of drugs that doctors canprescribe that can make psoriasis worse.
The two that you need to know about,I think, are lithium, which is used
for bipolar disorders, so just beaware of that, and anti-malarials.
(21:06):
So if you're going to a malariazone, the classic, quinolines,
things like, chloroquine andthings, those will make psoriasis
worse, and there are alternatives.
But there's a list of things thatcan make psoriasis worse and worth
talking to your doctor about those.
I should have mentioned alcohol earlier.
Alcohol, along with smoking, itdefinitely makes psoriasis worse.
(21:26):
And intriguingly, psoriasis is oneof those skin conditions where if
you have a tendency to psoriasisand you damage the skin, you can get
psoriasis in the newly damaged skin,which is the last thing you need.
So if you just had an operation,and you've got psoriasis, you
can get psoriasis in the scar,or if you get sunburn, you can
get psoriasis in the sunburn.
So we're aware that it likes damaged skin.
(21:47):
And so we've got our patient, we'vetaken a good history from them.
If someone goes along to their doctor,to talk about their psoriasis, what
are the sort of things that they couldexpect their doctor to be talking
about, when they're assessing them?
(22:09):
Well, I'd suggest it'd be a goodidea to take with you all the
current treatments that you're using.
And I'd include in that, anyshampoos, any face products, what
you're washing with, your soaps.
I hope you're not using soap.
Your washing agents though.
So everything that you're using,including things you buy over the
counter that you're using on your skin.
(22:30):
So take those with you and I'dlike to think the doctor might want
to have a look at those and seewhat you're using and see how much
you're using, where you're using it.
I'd hope that the doctor would allow youto tell them what's going on and what's in
your mind and what you're worried about.
I hope that they'd sit back and allowyou to have the space to put them in
(22:52):
the picture, to put the doctor into thefull picture, they know what's going on.
If you've got any joint trouble, jointpains, joint stiffness, joint swelling,
significant low back pain and earlymorning stiffness in the back, which I
think most of us do have to some extent,but if you've got significant joint
trouble, for goodness sake, be sure totell your doctor that you've got psoriasis
(23:15):
and you're worried about your joints.
That's a very, very importantarea of psoriasis management.
It generally merits urgentreferral to a joint specialist.
There's no reason why you couldn'tdownload what's called the Dermatology
Life Quality Index, the DLQI, and youcan download that easily online, and
(23:37):
it's a questionnaire, has 10 questions,each with the potential of a score up
to three, so a maximum score is 30.
And I would suggest it's not a badidea, if you're going to see a doctor,
just to fill out one of those, printit off at home and take it with
you and say my DLQI currently is.
If your DLQI is less than 5, it'sunlikely that the psoriasis is
(23:59):
having much impact on your life.
Between 5 and 10, I take itseriously and I know that we
need to do something about this.
If it was over 10, if we can'tget it lower than that, that's a
justification of going on to reallysuper potent things like biologicals.
So, we take a DLQI over 10 as having amassive impact on the patient's lifestyle.
(24:20):
I've occasionally seen this in the 20s.
So it's very useful.
It can also alert you to some ofthe things that psoriasis can do.
So you may say, "oh, other people withpsoriasis are having this problem.
I might tell my doctor aboutthat or alert them to that."
So definitely do a DLQI yourself.
And go prepared to be examined.
(24:42):
I think if the doctor knowswhat they're doing, they're
going to want to feel your skin.
They're going to want to look atyour skin, they should be looking at
your hair, and at your hair marginsand at the very least, they need to
ask you about the flexural areas.
So they may want to look at your armpitsand your groin, and at the crack between
your buttocks, or under your breasts.
And this is good practice.
(25:03):
So go prepared to be examined.
I think that's an important message there.
I think that's really good overviewand a nice little point to bring
this little chat to a close.
So George and I do hope you foundthis chat, about this very common, but
highly life impacting skin problem,interesting, and you found the
overview helpful and even given youthe confidence to go and speak to your
(25:26):
doctor about it if you haven't already.
Roger and I hope you'll join usagain in two weeks time where we'll
be discussing the management ofpsoriasis in a bit more detail.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
We couldn't have done it without them.
So until then, it's goodbye from George.
Goodbye.
And as always, it's goodbye from me.
(25:48):
Goodbye.
this podcast discusses suicidal feelings, which
some listeners may find distressing.
Hello and welcome to this Skin Deeppodcast, where we look at skin-related
(00:23):
issues, conditions and treatmentsin an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff.
I was also a GP, though I'mnow retired from my practice.
And I was the Chair of theDermatology Council for England.
Now today, George and I are going tobe talking about psoriasis, and what
(00:43):
we should know about before we look totreat it, and this is the first of two
podcasts on this very common condition,with its treatment being the subject
of the second one in two weeks time.
So do make a note to check that out.
(01:04):
But, first of all George, I do thinkit's helpful to talk about the definition
of psoriasis, because many peoplelistening might not understand very
clearly exactly what the condition is.
Psoriasis is a skindisorder which is chronic.
In other words, it goes on and on.
So if you have psoriasis, the chancesare you may come back with it at a later
(01:24):
stage in your life, even if it clears up.
But I think it's important to sayfrom the outset, it's non-infectious,
it's not contagious and it'san inflammatory skin disorder.
The skin is inflamed.
And when you look at it, youtypically have these well-defined,
red areas of abnormal skin, whichhas a very typical silvery scale.
(01:46):
The scale easily falls off, but itgets air underneath it, which means
that when you look at it, it hasthat sort of silvery look to it.
So it's a chronic, non-infectious,inflammatory skin disorder with
well-defined red plaques, is whatdoctors call them, and silvery scale.
And I think many people listening willstart to recognise that either on people
(02:07):
they've seen themselves or even from thecondition that they've got, which is maybe
one of the reasons why they're listening.
But the cause, the epidemiology, if I canuse that term, it's really interesting
as to why someone with psoriasisshould have, psoriasis, isn't it?
Well, yes, it is one of the most commonskin conditions, one of the most common
(02:28):
conditions, that our society suffers with.
So it is extremely common.
And what advantage does that have?
Why is it there?
I think this is really quite fascinating.
It's common in those societies,today, that in the past were
affected by scarlet fever.
(02:48):
Psoriasis offers some protection againstthe bacteria that causes scarlet fever,
the streptococcus, and we've justgone through a minor epidemic of that.
The streptococcus appears to becoming a little bit more, vigorous
and virulent in recent years.
But in the past it was, talking 70years ago, it was really frightening.
(03:10):
It was pre-antibiotic era, and itkilled a large number of people,
a very large number of children.
And in scarlet fever, yourskin becomes bright red.
It can peel off, and if it's reallysevere, you can then start losing a
lot of fluid, your blood volume drops.
You don't perfuse important thingslike your liver and your kidneys,
(03:33):
they start to fail, and you die.
Well you can die rather, it's a nasty,dangerous illness, scarlet fever.
And it's not as virulenttoday as it was 100 years ago.
But if you've got a tendency topsoriasis, you're relatively protected.
Instead of getting red skin andskin peeling off, you get thickening
of the skin and raising up, whatdoctors call hyperkeratosis,
(03:57):
these plaques of psoriasis.
And in particular, you get apattern we call guttate psoriasis.
From the Latin guttae, "a raindrop".
It looks like you've got little raindropsof psoriasis all over your body.
And that typically comes on a couple ofweeks after encountering a streptococcal,
a bad streptococcal infection.
So you don't die, you havean inconvenient skin rash.
(04:21):
And that confers enormous advantageto you, and that probably accounts
for why the genes persisted.
If you look today where psoriasisoccurs, it occurs in those societies
where scarlet fever killed.
So, for example, compare theNorth of China to the South.
Psoriasis today is four times morecommon in the North than the South.
Looking at their records in the19th century, scarlet fever was
(04:45):
four times more common in theNorth of China than the South.
Aborigines had no scarlet fever,they had no psoriasis until we
brought our genes into their genepool, and the same with Indians.
So, it's very, very interestinglooking at that relationship.
So psoriasis does confer someadvantages, more than that actually.
If you've got psoriasis, you harbourthe bacteria in your throat, where
(05:09):
it does you no harm, and you can thenpopulate the next epidemic of scarlet
fever, killing off your geneticcompetition; people who haven't got
the advantage of having psoriasis.
But the headline figures are,yeah, it affects roughly 2% of
the world population, and that'sabout the prevalence in the UK.
In the world, 125 million people with it.
(05:30):
It's much more common in white Americanswho migrated to America from Scandinavian
countries where scarlet fever wascommon, 4.6% in white Americans.
Less than 1% of blackAmericans have psoriasis.
And it affects men and women equally.
Although it often starts inchildhood, typically with that guttate
(05:51):
pattern following a sore throat.
Roughly a third of people firstencounter, first have their psoriasis
as a child or a young teenager.
And genetics plays a huge role.
This is a multigene condition,where polygenic, in other
words, isn't just one gene.
It may be a combination of genes.
But 40% of patients with psoriasishave a family history and the more
(06:16):
members of your family there are,with psoriasis, the more likely you
are to get psoriasis earlier, andthe more severe it's going to be.
But, there are over 60 genes, that,we wonder whether those might account
for some of the different patternsof psoriasis we sometimes see.
Yeah, so it's much more complex thanmight initially appear and you'd
think that although it is a complexcondition, you'd think diagnosing
(06:39):
it would be fairly straightforward.
In other words, you'd rock up to yourdoctor surgery, they'd take a look at
your skin patches and there you are.
But one of the things I've learntover too many years of treating
patients with psoriasis, there are ahuge range of possible presentations.
So it can make the diagnosis alittle bit trickier than people
might think so there are a numberof patterns of psoriasis out there.
(07:04):
The most common pattern, is called"chronic stable plaque psoriasis".
And that classically affects the backs ofthe elbows and the fronts of the knees.
Often on the body, on the buttocksand around the place, it can be quite
severe and cover large areas of skin,and that's probably the most common.
The scalp is very commonly affected,probably about 4 out of 5 patients
(07:27):
have involvement of their scalp andit's not necessarily visible because
hair will cover that very effectively.
But if you lift the hair up,you can see it just creeping
just beyond the hair margin.
So very, very common.
It can affect the nails.
The nails can be really troublesome,and often you just get minor changes,
like little holes drilled intothem, we call that pitting, or the
(07:50):
nail can lift off from the nailbed, which is quite unpleasant,
with a lot of scale and thickeningof the tissue underneath the nail.
People don't recognise it,often miss flexural psoriasis.
It can go for the armpits and thegroin and the buttock crease and
under the breast in these sort ofmoist areas and can be a bit tricky
(08:10):
there because it doesn't look quitethe same as psoriasis elsewhere.
It hasn't got that dry, scaly look.
It just looks glazed, sharplydemarcated as it typically is in
the plaque psoriasis but without thescale it just looks shiny and glazed
and can be often misdiagnosed there.
And then there are other patterns too.
(08:31):
But I think the important thingis if you're seeing somebody
with psoriasis is to look atthem as holistically as you can.
You need to find out abouttheir family history.
You need to think about any aggravatingfactors that might be going on that
are driving it and then you lookcarefully and you feel the plaques.
I think, as a doctor, it's so important totouch our patients, with their permission,
(08:52):
wash our hands and then touch them.
Feel their plaques, because societygenerally is repelled by skin disease
and patients with psoriasis oftenfeel quite ostracised by that.
And I think for a physician to be preparedto go straight in and feel their plaques,
examine the nature of the scale, lookingcarefully at all the nails and asking
about the flexures, feeling the scalp.
(09:14):
I think that's so important and sothat's part of my assessment there.
Of course, and you mentioned patientswith skin conditions feeling, ostracised
and this is perhaps greater thanever with people with psoriasis.
Whenever I've given talks atconferences about psoriasis and
mentioned the psychological impactof psoriasis, including some truly
(09:38):
dreadful suicide statistics in theUK of people with psoriasis killing
themselves simply because of thepsychological impact of their psoriasis.
You can usually hear a pin drop inthe room as those facts sink in.
Now, regular listeners to thispodcast will know that I don't talk
about individual patients, often.
(09:59):
But in this case, I am going tomention a particular patient.
I have changed details so they can't beidentified, and it was a long time ago.
So I'm not breaking any confidences here.
But the reason I would mention this oneis that this completely altered how I
viewed patients with psoriasis forever.
In fact, it altered how I viewed patientswith all skin conditions forever.
(10:20):
Which was a highly successfulbusinessman, single man, late thirties,
been having treatment for psoriasispretty much for over a decade.
Seen a lot of my colleagues, andeventually rocked up in front of my desk,
I think more in desperation than anything.
(10:41):
I was a senior partner in practice,and he thought that, well, I'll go
and see, you know, the senior partner.
Patients sometimes think thatbecause you're senior partner,
you know more, which is untrue,but that's a psychological fact
of what can sometimes happen.
And he sat down and we were talkingabout psoriasis and how he was wanting
to try and get to the bottom of this andthen he promptly burst into tears on me.
(11:06):
Which really took us, I think, both back.
He was a chap who tended to sort ofkeep his emotions to himself, and so
we explored that, and going throughquite a long consultation, into a
nutshell, he said that he was just,desperately, desperately lonely.
(11:28):
He could not be in a relationshipand had not been in a relationship
because of the impact of psoriasisand the shame he felt from it.
He had not had physical contact.
He had not hugged someone for yearsbecause he was ashamed about his psoriasis
and he was a single man because hecould not bear anyone seeing him in the
(11:52):
morning, hoovering the skin flakes outof his bed, and that's why he was single.
And that really dropped thescales from my eyes and I really
understood then the impact,psychologically, of skin conditions.
We fortunately managed to get hispsoriasis controlled, and better.
(12:16):
And a couple of years later I justhappened to see him in passing and he
was as happy as I've ever seen anyone,in a lovely relationship, and that
has continued through to this day.
But I think the point of that is thatfor some people with psoriasis, the
physical impact of this visible conditionabsolutely pales, compared to the impact
(12:38):
it does on their mental health, and Isuspect you've had many similar stories.
I have, but that is a very lovely andpowerful story, and I can understand
how it would change my practiceas well, for the better, I hope.
Ah, it's so easy not to hear about thedistress, somebody else is suffering.
(12:59):
Humans have that extraordinary capacityto turn a blind ear to that sort of thing.
And I think that shame, that wordshame really resonates with me.
Isn't that awful for him?
What a lovely, lovely outcome.
And I think that in this modern worldwe live in, skin disease is something
(13:20):
that people are repelled by, andparticularly with young people who
are using social media, where how theylook is being noticed and commented
on and criticised is so powerful.
I think we need to bevery, very alert to this.
Because skin diseases are visible.
It's often the first thingsomeone notices when they see you.
(13:44):
And we're wired to be repelled byphysical deformities, and patients
experience that all day, every day.
So it's no surprise that skindiseases punch way above the
objective severity when it comes tothe impact on their life experience.
A study about 5 years ago showed that morethan 4 out of 5 patients with psoriasis
(14:06):
reported that they had experienceddiscrimination or humiliation because
of their psoriasis, and almost a halfreported it had adversely affected
their personal relationships, especiallyintimate, as in your patient's case.
So I think it's something weneed to be very, very alert to.
Nowadays, we're increasingly talkingabout what we call the cumulative
(14:29):
life course impairment, that adisease like psoriasis can cause.
You can imagine how some loss ofself-esteem because of your psoriasis
and loss of confidence as a teenagercan mean that you decide not to
try to join a team or even remainin school to do your A-levels.
And then underachievement at schoolmeans you underachieve after school.
(14:52):
You don't get the furthereducation opportunities.
Career options are limited and missed.
And it has an increasing potentialimpact on relationships, which you
may never want to embark on, likeyour man, or you do and they fail.
And the consequences of what might to manyjust seem as a trivial skin condition, a
bit of scale on the backs of your elbowsand the fronts of your knees, can progress
(15:16):
to have a devastating and lifelong impact.
And I think we need to really wake upto that and recognise that this matters.
Yes, I cringe when I hear people say,"you've got a touch of psoriasis."
It's like saying "you'rea little bit pregnant."
It's, you know, irrespective ofthe severity of the psoriasis,
(15:39):
and this has been replicated in anumber of studies looking at other
conditions like eczema and acne.
There is no direct link between howsevere the skin condition is and how
severe the psychological impacts.
You can have a relatively mildskin disease and absolutely
enormous, psychological impacts.
(16:01):
There is something that youjust mentioned earlier and I
just wanted to pick up on it.
You said that psoriasis is an inflammatorycondition, which might be an interesting
statement to some people listening.
Why did you make that point?
Well, I stressed it, didn't I?
Yeah.
Chronic inflammation from whatever'sdriving it, whether it's arthritis
(16:23):
or psoriasis, or even eczema.
We now know even badeczema, is bad for you.
And it's particularlybad for our arteries.
It causes hardening of the arteries.
So, it accelerates the rateat which that gets worse.
So controlling inflammation, werecognise now, is so important.
You cannot leave chronic lowgrade background inflammation.
(16:45):
It will increase your riskof heart attacks and strokes.
Psoriasis is also associated with centralobesity, that's sort of fat tummies.
And that's linked to acceleratedheart disease and diabetes.
And, in fact, psoriasis is alsoassociated with an increased risk
of diabetes and the condition of theliver where you get fat deposits in the
(17:06):
liver causing it to not work so well.
So, non-alcoholic fatty liver diseaseand diabetes are other concerns.
These are very, very important for GPsand I think that if you have moderate
or severe psoriasis, I think it'sworth talking to your doctor about
your overall risk for heart diseaseand asking if they can do what's called
(17:27):
a QRISK, which is putting togetheryour blood pressure, your cholesterol,
whether you smoke or not, and so on.
Putting all those together to givesome sort of measure of how high
your risk is for heart disease.
And taking that into the context ofsomeone with chronic inflammation, it
means that you might address some ofthose risk factors more aggressively.
(17:50):
Yeah.
Inflammation really matters.
Yeah.
I think anyone who's listening withpsoriasis, will know from experience just
how quickly their psoriasis can go fromwell-controlled to a significant flare.
Almost to the point of being out ofcontrol when certain factors trigger
(18:11):
it, almost like petrol on a fire.
So I sometimes say that, you know,well-controlled psoriasis hasn't
gone away; it's just there likeembers of a fire and then certain
things can throw petrol on it.
So I often think of the four S's whenI'm looking at patients with psoriasis.
There's potential triggers,although there are lots more,
and you probably mentioned them.
But things like, as you say,streptococcal infection, smoking,
(18:34):
absolute, and we'll touch on this,a big no no, stress, and steroids.
And those are my four.
I always sort of go down thelist first, although there
are some more on top of that.
I love those four S's.
It's so helpful, isn't it?
Yep, so streptococcal infections.
And interestingly, I mentionedthat patients with psoriasis often
harbour that bacteria in their throatand they have more sore throats.
(18:57):
But the strep can be a sort of chronicsort of stimulus for more psoriasis.
People have tried penicillin to try anderadicate it, but it doesn't seem to help.
So that's not the answer.
But there's certainly that link.
Yeah, smoking.
Smoking does make psoriasis worse.
But also, like psoriasis,it hardens the arteries.
(19:20):
So you've got a double whammythere, really bad news.
And it's also the driver for a very,very nasty, though not uncommon,
fairly uncommon rather, pustularcondition that occurs on the hands,
or feet; can be very disabling.
I haven't seen that insomeone who's never smoked.
So, an important message.
If you've got psoriasis,you shouldn't be smoking.
(19:41):
Absolutely not.
Stress, well we've alreadycovered the fact that psoriasis
is stressful, but stress seemsto make psoriasis worse as well.
So you're into a vicious cycle there.
The worse your psoriasis, the morestressed you're going to feel, the
more stressed you're going to feel,the more, it's going to be making
the psoriasis worse and so on.
So, not necessarily easy toaddress that but certainly being
(20:03):
alert to the stresses in your lifeand see what you can do there.
Steroids, I don't like usingsteroids on their own, on the
skin, in patients with psoriasis.
I think that if I ever prescribe a steroidtopically, for psoriasis, I'd want to
use another agent to go alongside it.
Because that can, particularly whenyou stop, withdraw the steroid,
(20:24):
it can trigger a severe flare.
And I've even seen terrible flaresof psoriasis when people have been
on steroids for something else.
Acute asthma, or whatever, andthey've been on a steroid, is when
you stop the steroid, things cansuddenly go dramatically and very
severely out of control, rarelyputting the patient on intensive care.
(20:44):
So I personally say don't use topicalsteroids on their own for psoriasis
There are a lot of drugs that doctors canprescribe that can make psoriasis worse.
The two that you need to know about,I think, are lithium, which is used
for bipolar disorders, so just beaware of that, and anti-malarials.
(21:06):
So if you're going to a malariazone, the classic, quinolines,
things like, chloroquine andthings, those will make psoriasis
worse, and there are alternatives.
But there's a list of things thatcan make psoriasis worse and worth
talking to your doctor about those.
I should have mentioned alcohol earlier.
Alcohol, along with smoking, itdefinitely makes psoriasis worse.
(21:26):
And intriguingly, psoriasis is oneof those skin conditions where if
you have a tendency to psoriasisand you damage the skin, you can get
psoriasis in the newly damaged skin,which is the last thing you need.
So if you just had an operation,and you've got psoriasis, you
can get psoriasis in the scar,or if you get sunburn, you can
get psoriasis in the sunburn.
So we're aware that it likes damaged skin.
(21:47):
And so we've got our patient, we'vetaken a good history from them.
If someone goes along to their doctor,to talk about their psoriasis, what
are the sort of things that they couldexpect their doctor to be talking
about, when they're assessing them?
(22:09):
Well, I'd suggest it'd be a goodidea to take with you all the
current treatments that you're using.
And I'd include in that, anyshampoos, any face products, what
you're washing with, your soaps.
I hope you're not using soap.
Your washing agents though.
So everything that you're using,including things you buy over the
counter that you're using on your skin.
(22:30):
So take those with you and I'dlike to think the doctor might want
to have a look at those and seewhat you're using and see how much
you're using, where you're using it.
I'd hope that the doctor would allow youto tell them what's going on and what's in
your mind and what you're worried about.
I hope that they'd sit back and allowyou to have the space to put them in
(22:52):
the picture, to put the doctor into thefull picture, they know what's going on.
If you've got any joint trouble, jointpains, joint stiffness, joint swelling,
significant low back pain and earlymorning stiffness in the back, which I
think most of us do have to some extent,but if you've got significant joint
trouble, for goodness sake, be sure totell your doctor that you've got psoriasis
(23:15):
and you're worried about your joints.
That's a very, very importantarea of psoriasis management.
It generally merits urgentreferral to a joint specialist.
There's no reason why you couldn'tdownload what's called the Dermatology
Life Quality Index, the DLQI, and youcan download that easily online, and
(23:37):
it's a questionnaire, has 10 questions,each with the potential of a score up
to three, so a maximum score is 30.
And I would suggest it's not a badidea, if you're going to see a doctor,
just to fill out one of those, printit off at home and take it with
you and say my DLQI currently is.
If your DLQI is less than 5, it'sunlikely that the psoriasis is
(23:59):
having much impact on your life.
Between 5 and 10, I take itseriously and I know that we
need to do something about this.
If it was over 10, if we can'tget it lower than that, that's a
justification of going on to reallysuper potent things like biologicals.
So, we take a DLQI over 10 as having amassive impact on the patient's lifestyle.
(24:20):
I've occasionally seen this in the 20s.
So it's very useful.
It can also alert you to some ofthe things that psoriasis can do.
So you may say, "oh, other people withpsoriasis are having this problem.
I might tell my doctor aboutthat or alert them to that."
So definitely do a DLQI yourself.
And go prepared to be examined.
(24:42):
I think if the doctor knowswhat they're doing, they're
going to want to feel your skin.
They're going to want to look atyour skin, they should be looking at
your hair, and at your hair marginsand at the very least, they need to
ask you about the flexural areas.
So they may want to look at your armpitsand your groin, and at the crack between
your buttocks, or under your breasts.
And this is good practice.
(25:03):
So go prepared to be examined.
I think that's an important message there.
I think that's really good overviewand a nice little point to bring
this little chat to a close.
So George and I do hope you foundthis chat, about this very common, but
highly life impacting skin problem,interesting, and you found the
overview helpful and even given youthe confidence to go and speak to your
(25:26):
doctor about it if you haven't already.
Roger and I hope you'll join usagain in two weeks time where we'll
be discussing the management ofpsoriasis in a bit more detail.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
We couldn't have done it without them.
So until then, it's goodbye from George.
Goodbye.
And as always, it's goodbye from me.
(25:48):
Goodbye.
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