Psoriasis
What it is, how it presents, the main types and how it can be treated
Psoriasis is a chronic inflammatory disease of the immune system that primarily affects the skin, although in many patients its impact extends beyond visible lesions.
It develops as a result of an altered immune response that accelerates skin cell turnover and causes cells to accumulate on the surface of the skin. This leads to characteristic lesions, usually red and covered with scale, whose extent, location and severity can vary considerably from one person to another.
Understanding what psoriasis is, how it can present and why it does not affect every patient in the same way is the first step towards assessing each case more accurately and choosing the most appropriate treatment.
What is psoriasis?
Psoriasis is a chronic, immune-mediated inflammatory disease that is not contagious. Although its best-known manifestations affect the skin, we now know that it should not always be understood solely as a skin condition.
In many patients, psoriasis can have a significant impact on physical wellbeing and quality of life and, in some cases, may be associated with other conditions that should also be taken into account. For this reason, psoriasis should not be underestimated, even when it appears to affect only a limited area of skin.
What causes psoriasis?
Psoriasis has an immunological basis and a genetic predisposition. A family history of psoriasis or other inflammatory diseases is common among patients.
In addition to this individual predisposition, certain factors may contribute to the onset of the disease or trigger flare-ups, including:
- stress;
- smoking;
- certain infections;
- some medications;
- and repeated trauma to the skin.
Not every patient responds to these factors in the same way, which is why each case should be assessed individually.
How does psoriasis present?
The most common form of psoriasis causes red skin lesions of varying size, often covered with whitish scales.
These lesions may cause itching, stinging, pain or discomfort in everyday life. In some patients, the emotional impact can also be considerable, particularly when psoriasis affects visible, persistent or difficult-to-treat areas.
Psoriasis may also affect the nails, causing changes such as:
- small depressions in the nail plate;
- thickening;
- partial separation of the nail;
- or colour changes, including so-called oil-drop changes.
Psoriasis is not contagious
Psoriasis in special locations
Not all psoriasis is the same, and different locations can affect patients in very different ways. Some areas can be particularly uncomfortable or difficult to manage even when the overall extent of psoriasis is limited.
Important locations include:
- the scalp;
- the hands;
- the feet;
- the face;
- skin folds;
- the genital area;
- and the nails.
These areas may require particularly careful assessment and precisely tailored treatment because their functional, emotional or social impact can be high even when psoriasis appears relatively limited.
Different forms of psoriasis require different treatment approaches
Types of psoriasis
Psoriasis can present in several different clinical forms. Identifying them correctly is important because they do not all follow the same course or require the same therapeutic approach.
Plaque psoriasis
This is the most common form.. It is characterised by well-defined red plaques covered with whitish scales. Common sites include the elbows, knees, scalp, lower back and the area behind the ears, although plaques can appear almost anywhere on the body.
Guttate psoriasis
This form presents with smaller, more numerous lesions, usually distributed across the trunk and limbs.
It may sometimes develop after an upper respiratory tract infection and is seen more frequently in younger people.
Palmoplantar pustular psoriasis
This form is characterised by pustules developing on red skin on the palms of the hands and soles of the feet.
Although it may affect only a small body surface area, it can have a major impact on quality of life and requires careful therapeutic assessment.
Erythrodermic psoriasis
This is a rare and severe form of psoriasis characterised by very widespread redness of the skin and intense symptoms. It requires prompt specialist medical assessment.
Inverse psoriasis
Inverse psoriasis affects skin folds such as the armpits, groin, area beneath the breasts and the intergluteal fold.
Lesions in these areas usually have less scaling and may be particularly uncomfortable because of friction, sweating and increased skin sensitivity.
Generalised pustular psoriasis
This is an uncommon but potentially severe form characterised by extensive redness and inflammation with widespread pustules. It requires specialist medical care.
Manifestations requiring particular attention
Some manifestations do not always fit neatly into the classic clinical types of psoriasis, but they are particularly relevant and should be assessed separately.
Nail psoriasis
Nail involvement is common in psoriasis and may present with pitting, oil-drop changes, thickening or separation of the nail from the nail bed. Its presence requires specific assessment and a treatment approach adapted to the individual case.
Scalp psoriasis
Scalp psoriasis is very common and can be particularly troublesome because of itching, the visibility of lesions and the difficulty of applying certain treatments effectively. It requires a carefully planned treatment approach adapted to the scalp.
My aim is to reduce the impact of psoriasis on your life
Psoriasis does not always stop at the skin
We now know that psoriasis may be associated with other conditions that can also affect a patient’s health and quality of life. Understanding psoriasis solely from the perspective of the skin would therefore be incomplete.
Important aspects to consider in many patients include:
- psoriatic arthritis;
- cardiovascular risk;
- metabolic syndrome;
- fatty liver disease;
- and the emotional impact associated with the condition.
How can psoriasis be treated?
A wide range of effective treatments is now available to manage psoriasis and improve disease control. The most appropriate treatment depends on several factors, including:
- the type of psoriasis;
- its extent;
- its location;
- its impact on quality of life;
- the presence of comorbidities;
- and the response to previous treatments.
Depending on the individual case, treatment may include:
- topical treatments;
- phototherapy;,
- systemic treatments;
- biological therapies;
- and other strategies tailored to specific locations or clinical situations.
The important issue is not simply having multiple options available, but knowing which is most appropriate at each stage and how treatment should be monitored.
Not all mild psoriasis is well controlled
Not every patient with mild or moderate psoriasis has genuinely good disease control. Many patients live for years with persistent lesions, poorly adjusted treatment regimens, limited treatment education or an unnecessary sense that they simply have to accept the condition.
Patients should not have to accept persistent plaques simply because their psoriasis does not appear severe enough. In many cases, a more precise assessment and a better-tailored treatment strategy can significantly improve disease control.
When can specialist assessment be helpful?
A more specialised assessment may be particularly useful when:
- psoriasis remains poorly controlled despite treatment;
- it affects particularly troublesome or visible areas;
- there is uncertainty about the diagnosis;
- the nails are affected;
- there are concerns about psoriatic arthritis or other comorbidities;
- or the patient would like to review whether their current treatment remains the most appropriate option.
Dr Álvaro González Cantero
Medical registration number: 454505859