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doi: 10.1046/j.1365-2230.2001.00832.xpmid: 11422182
Despite psoriasis being a common skin disease, there are still a number of unanswered questions. One of these is the prevalence of the disease, as there is a lack of specific data, with the majority of studies reporting estimates only. Population based studies are rare and longitudinal observations on changing prevalence rates are lacking. This contrasts with other T‐cell mediated autoimmune diseases where the number of those affected is rising.Epidemiological studies revealed that a distinct group of diseases is quite frequently associated with psoriasis, e.g. arthritis, colitis, diabetes and hypertension. In contrast, atopic dermatitis and allergies are less frequently seen compared to normal rates of occurrence. As the psoriatic immune response pattern relates to activated Th‐1 cells, psoriasis and atopic dermatitis appear to be mutually exclusive due to the Th‐1/Th‐2 dichotomy.
doi: 10.1046/j.1365-2230.2001.00830.xpmid: 11422183
Epidemiological studies indicate that genes play an important role in the pathogenesis of psoriasis. Multiple genes are likely to be involved, interacting not only with each other but also with the environment to cause disease expression. Molecular genetic studies indicate that there are multiple susceptibility loci present throughout the human genome. It is clear that a gene or genes of major impact on psoriasis is present on chromosome 6 within the major histocompatibility complex (MHC). Linkage disequilibrium studies indicate this gene to reside within a 300 kb interval centred around the centromeric end of class I MHC. Known candidate genes in this region are HLA‐C, corneodesmosin and HCR, although novel genes, as yet unknown, may also exist. There is accumulating evidence that HLA‐C is not itself the causative gene but rather a marker for it. Identification of the genes involved in psoriasis susceptibility will represent a step forward in our understanding of the disease and our future ability to help patients with psoriasis.
doi: 10.1046/j.1365-2230.2001.00831.xpmid: 11422184
The understanding of the pathogenesis of psoriasis vulgaris has advanced significantly since the therapeutic efficacy of immunosuppressive drugs has drawn attention to the role of immune mechanisms in psoriasis manifestation. Today, the results of many experimental studies provide evidence that psoriasis is largely a T‐cell mediated disorder. It may result from antigen‐specific activation of T cells in the skin of genetically predisposed individuals. These T cells apparently have a particular functional differentiation and promote the psoriatic skin changes by secreting a certain set of cytokines. Based on the fact that streptococcal throat infections are a trigger of guttate psoriasis, the putative psoriatic antigens are assumed to be in keratinocyte proteins that share structural homologies with streptococcal proteins and thus induce cross‐reactive responses of antibacterial T cells against skin components. Together with the particular phenotype of psoriatic skin lesions these findings suggest that psoriasis represents a sterile antibacterial tissue reaction, which is mediated by streptococci‐specific T cells that cross‐react against epidermal autoantigens.
Fearon, Ursula; Veale, Douglas J.
doi: 10.1046/j.1365-2230.2001.00792.xpmid: 11422185
Psoriasis and psoriatic arthritis have been recognized for more than 100 years. Neither the link between psoriasis of the skin or nails and arthritis of the joints nor the pathogenesis of either condition alone or in combination has yet been explained. Our understanding of the mechanisms of inflammation of the skin and the joints has improved over the past 30 years and there are some interesting common threads of knowledge that may bring us closer to understanding psoriasis and psoriatic arthritis. This article will explore further the areas of immunogenetics, infection, autoimmunity, vascular morphology/angiogenesis, trauma and the nervous system in respect of psoriasis and psoriatic arthritis highlighting in particular those aspects that previously have not received due reference.
Griffiths, C. E. M.; Richards, H. L.
doi: 10.1046/j.1365-2230.2001.00834.xpmid: 11422186
It has long been recognized that living with a chronic condition, such as psoriasis, can have considerable impact on the individual concerned. In turn there is increased understanding that the psychological distress encountered as a result of this experience can have implications for the course of the disease. This short review takes this as a starting point and reviews psychological influences in psoriasis. The nature of the link between psoriasis and stress is explored and its implications for the patient are discussed in psychological and clinical terms. There seems little doubt that stress, either environmental or psoriasis induced, impacts on our patients and has important implications for the management of psoriasis.
doi: 10.1046/j.1365-2230.2001.00828.xpmid: 11422187
This review covers the current practice of phototherapy with ultraviolet (UV) radiation without sensitizers and of psoralen photochemotherapy (PUVA) in the treatment of psoriasis. Both treatment modalities are well established in today's therapeutic armamentarium. Phototherapeutic regimens use repeated controlled UV exposures to alter cutaneous biology, aiming to induce remission of skin disease. Although UVB has been used for a longer time than PUVA, the latter has been evaluated and validated in a more detailed and coordinated fashion.
doi: 10.1046/j.1365-2230.2001.00833.xpmid: 11422188
Day care treatment centres provide the best solution for the treatment of most patients with psoriasis. The centre is not only ideal for treatment but has other roles, such as education of patients and nurses. The specialist dermatology nurse is the key to success. Out patient treatment of psoriasis is less expensive than in patient treatment. The development of a treatment centre should be seen as an additional facility and not as a substitute for in patient beds.
doi: 10.1046/j.1365-2230.2001.00829.xpmid: 11422189
Long‐term management of psoriasis requires an individualized approach. Some treatments such as calcipotriol, methotrexate and acitretin may be used as maintenance treatment for many months. However, most anti‐psoriasis treatments should be prescribed for restricted periods of time. Rotational treatment is a practical approach to reduce the cumulative toxicity of anti‐psoriasis treatments. The selection of a treatment is based on the clinical presentation of psoriasis and whether contraindications might exist. Combination treatment is another approach, which is used by the majority of patients. Useful combinations are calcipotriol–acitretin, calcipotriol–cyclosporin, calcipotriol–PUVA, calcipotriol–topical corticosteroids, dithranol–UVB, dithranol–tar, coaltar–UVB, acitretin–UVB and acitretin–PUVA. Combinations which are contraindicated are coaltar–PUVA, UVB–cyclosporin, PUVA–cyclosporin and methotrexate–acitretin. Combined use of UVB–methotrexate, UVB–PUVA; PUVA–methotrexate; methotrexate–cyclosporin and cyclosporin–acitretin require careful monitoring and might be helpful in patients with severe and recalcitrant psoriasis. Depending on the individual presentation of psoriasis, previous anti‐psoriatic treatments and side‐effects, treatment adjustments are made.
doi: 10.1046/j.1365-2230.2001.00835.xpmid: 11422190
Severe cases of psoriasis and psoriasis arthritis require systemic treatment. Although a number of established drugs are in clinical use, there is a need for new compounds with an improved risk‐benefit ratio with a major emphasis on long‐term safety. Furthermore, patients with moderate psoriasis ask for systemic drugs to make therapy easier and to avoid excessive local treatments.This article aims to give a brief overview about new drugs or groups of compounds together with an evaluation of their present status in the treatment of psoriasis and their future role with particular respect to efficacy, tolerability, safety and usability.
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