Ayurvedic Insights into the Pathogenesis and Management of Psoriasis

Psoriasis is an autoimmune disease affecting the integumentary system or the skin majorly. It is a chronic skin condition with itchy and inflamed skin lesions of grey, purple, red, pink, white, or silverish color with whitish or silverish-grey scales causing discomfort. It can affect any part of the body especially the scalp, knee, elbow, trunk and even nails and face.

Causes

The exact cause of the disease is not known. Psoriasis is a non-communicable, non-contagious skin disorder that affects many individuals.

Research shows the important role of Genetics as it runs down the family.

It also shows the importance to environmental factors.

Pathophysiology

Psoriasis is a chronic autoimmune disease having its own inflammatory and healing phases.

In the inflammatory stage, the disease flares up when the body’s immune system attacks its own cells causing inflammation. It causes skin disease where the skin cells grow more rapidly than usual. These unwanted excess skin cells, which are not fully mature and not nourished enough, pile up to form dry, scaly patches, a common symptom of psoriasis. On scratching the shedding of scales exposes multiple small bleeding points.

Signs and symptoms - Presentation of Psoriatic lesions

The lesion is usually presented as :

Dandruff-like scaling of whitish or silverish powder
When rubbed or scratched turns dusty or flaky and may fall off
The skin will be slightly inflamed with purple, red, pink, or greyish in color.
Multiple small bleeding points may be visible on removing the scales deliberately.
The scales can be dry or greasy in different types of Psoriasis.

The patient complaints of :

Discoloration, Itching, Pain, and or burning sensation.
Cracked, dry skin
Pitted, cracked, or crumbled nails
Joint pain
The condition on the severity will even affect the mental condition of the patient with regards to his self-esteem leading to depression, anxiety, etc.

Types of Psoriasis

Plaque Psoriasis : It is the most common type of Psoriasis found. The lesion is inflamed skin covered with dry, itchy scales. On healing leaves greyish, brownish, or blackish colour.
Guttage Psoriasis It is the type mostly seen in young adults and children, often linked to the pathogenesis of psoriasis. It usually occurs after a bacterial infection like strep throat. The lesion is characterized by drop-shaped spots covered by scales seen over the trunk, arms, and legs, typical of guttate psoriasis.
Nail Psoriasis : Psoriasis affects the fingernails and toenails causing pitting, discoloration, and abnormal nail growth. The progress of the disease causes Onycholysis in which the affected nails get loosened and fall off. In severe cases, nails get crumbled.
Inverse Psoriasis : The lesion with smooth patches of inflamed skin seen over the skin folds of the groin, buttocks, and breast. It gets worse with sweating and friction. This type of Psoriasis is triggered by fungal infections.
Pustular Psoriasis : It is a rare type presented with pus-filled blistered over palms and soles in small or widespread patches.
Erythrodermic Psoriasis : This least common type of Psoriasis can be acute or chronic. It can be extended over the whole body as a peeling rash with itching and burning.

Triggers for the development of Psoriasis

Usually in many cases, the people having Psoriasis will be asymptomatic until getting triggered by the factors like:

Infections like strep throat or any skin infections
Whether – cold dry conditions Eg: Winters
Skin injury – cuts, bites, burns, sunburns, etc
Smoking – active or passive secondary smoking
Alcohol
Medications – Lithium-containing medicines, Certain Anti-hypertensive medications, Anti-malarial medicines
Rapid withdrawal of Corticosteroids

Risk Factors

The main risk factors for developing Psoriasis is

Hereditary/Familial : Psoriasis runs down in families. Having one of the parents or both the parents psoriatic, successively increases the chance of developing the disease in the child.

In certain cases, the history of occurrence is usually found in siblings and grandparents too.

Smoking: This habit not only increases the occurrence but also the severity.

Aggravating factors

The factors that worsen Psoriasis are :

Diet – Milk, Curd, and other dairy products, Fish, Meat, Eggs, and other Non-veg food items, Sause, canned items, marine foods, etc
Lifestyle - sedentary lifestyles, habitual sleeping soon after having heavy meals, etc.
Indigestion or habitual intake of food before the digestion of the previous meal
Anxiety or stress
Smoking
Unhygienic practices

Relieving factors

Factors that help in the treatment or reducing the symptoms and complications of Psoriasis are :

Healthy food and lifestyle
Moisturising the skin to avoid cracks and bleeding
Meditation to reduce stress
Regular intake of medicines as advised by the physician
Maintaining Hygiene
Avoiding the aggravating factors

When to see a Doctor

The patient is advised to seek medical assistance when :

Leision is spreading and or getting severe
Causes increased discomfort or pain, which can be alleviated with appropriate psoriasis treatment.
Increased sleep disturbance
Leading to complications
Patient falling into depression and low self-esteem
Treatment seems to be giving not much improvement to the symptoms

Complications

Psoriatic arthritis – the autoimmune disease in the long run left untreated leads to inflammation, pain, and stiffness of the joints especially over knees, ankles, elbows, etc.
Temporary discoloration of the skin – will get improve with healing and treatments
Eye diseases – inflammatory ophthalmic ailments like Conjunctivitis, Blepharitis, Uveitis, etc
Obesity
Cardiovascular disease
Hypertension
Autoimmune diseases like Celiac disease, Sclerosis, Inflammatory bowel Disease – Crohn’s disease
Mental health – depression

Tests

Candle-grease test – The lesion is rubbed with a thin strip to obtain greasy candle wax-like scales.
Auspitz sign/ Scratch test – Scratch or remove the flakes with a strip that exposes small bleeding points beneath.

Diagnostic techniques

· Skin examination

· Skin biopsy – can determine the type of Psoriasis, and also rule out other conditions

· Blood test - HLAB27 , done for autoimmune diseases

Imaging technics

· Dermoscopy – Helps in diagnosing and assessing lesions of nails, scalp, soles, and genital regions

· High-Frequency Ultra Sounds (HFUS) – useful in Psoriasis Vulgaris

· Optical Coherence Tomography (OCT) – Provides high-resolution images of skin lesions.

Prognosis

Psoriasis is a chronic autoimmune disease. It is a manageable disease. The lesions can be completely relieved for a certain period of time with appropriate diet and lifestyle management along with proper medications. But the disease can recur and flare up with a slight change in the diet or environmental conditions or any other factors, a recent infection, etc.

Treatment

Common Psoriatic treatments include :

· Moisturisers – use moisturizers regularly

· Medicated lotions and shampoos

· Vit D3 ointments

· Vit A or retinoid creams

· Steroid creams

· Avoid harsh soaps, exfoliants

· Light therapy – To reduce inflammation and slow down uncontrolled cell production

· PUFA

· Immune therapies - biologics, inhibitors to block autoimmune reactions

· Methotrexate

· Cyclosporine – used in severe conditions

Ayurvedic Approach on Psoriasis

In Ayurveda, Psoriasis is correlated with the Mahakushta–Sidhma. Ayurveda emphasizes diet and lifestyle management in the treatment of skin diseases.

The treatment modalities include Snehana (oleation), Swedana, Virechana, and special treatments like Kasayadhara, Thakradhara, Abhyanga, lepana etc with appropriate formulations and internal medications.