Psoriasis: practical recommendations from DermaClub

Psoriasis is a puzzling, unpredictable and complicated condition. Thanks to the relatively recent development of biologic drugs, there is now a better understanding of the causes of and treatment for the disease.
Now that treatment options have improved, however, there is a risk that only the most severe forms of psoriasis – those that require hospitalization – are concentrated on, with more generalized cases being overlooked. Psoriasis is, however, a daily nuisance for millions of people across the world and it is to them that this paper is dedicated.
The reflections and suggestions within this guide are the fruit of DermaClub’s considerable experience over the years. This wealth of knowledge has been combined to incorporate modern, more suitable topical products than were available in the past.

Psoriatic skin under the magnifying glass

When the skin or nails are affected by psoriasis, it means that the process of keratinization has not been completed. Keratinization is the process that produces a thin, compact stratum corneum and a compact, transparent nail plate.

Healthy stratum corneum

Psoriatic stratum corneum

Healthy nail

Psoriatic nail

A healthy stratum corneum is compact yet supple, allowing it to flex without cracking. On the other hand, the psoriatic stratum corneum is rigid and prone to breaking during movement. The stratum corneum provides a barrier function toward external harmful agents, while a psoriatic stratum corneum is permeable to everything, from microorganisms and environmental pollutants, to even water itself. The same applies to the nail plate. When healthy, it is compact and impenetrable but, if psoriatic, it is pitted and will be easily penetrated by microorganisms, dirt and water. Therefore, regardless of therapeutic treatments, particular care and precautions must be taken to minimize daily inconveniences for the individual as far as possible.

Psoriasis on the scalp

Psoriasis often localizes on the scalp, sometimes as the sole area of manifestation.
Scalp psoriasis is particularly troublesome and can cause significant discomfort: it is frequently itchy, continuously sheds scales that are visible on clothing, and often extends beyond the hairline, making it more noticeable. In some cases, larger scaly plaques form, which are usually itchy. Scalp psoriasis is challenging to treat, especially in the presence of hair. For the plaque form, 2S Cream should be applied in the evening, using a small amount and massaging each plaque thoroughly with patience. Treatment should continue until the plaques have disappeared. For the scaly form (dandruff-like psoriasis), both 2S Cream and Glicosal Lotion can be used. The lotion is particularly practical and convenient for individuals with long or thick hair. In this case, apply approximately 10 drops across the scalp using a dropper, spacing them apart, then massage with your fingers to spread the lotion evenly across the scalp and allow it to absorb. However, scalp psoriasis often persists despite these treatments, in which case it may be advisable to stop washing the hair altogether. Hair washing can be an irritant for psoriasis. If hair washing is suspended, the hair can be cleaned from the outside with a Potassium Permanganate solution. This involves wiping the hair with a cotton cloth moistened with the solution, as detailed in a specific guide. For those with scalp psoriasis who wish to avoid worsening the condition, the hair-washing method is very important. Shampoos typically contain surfactants (the foaming agents) that can irritate psoriatic skin, so to achieve remission of scalp psoriasis, it is essential to both reduce washing frequency and avoid massaging or rubbing shampoo into the scalp. The washing process should proceed as follows: wet the hair, place a small amount of shampoo on the hand, and then gently apply the shampoo to the hair from the outside, taking care to avoid contact with the scalp. Rinse immediately afterward.

Shampoos for psoriasis

The cosmetic and pharmaceutical industries produce various types of shampoos, with so-called “medicated” shampoos touted as a cure for psoriasis of the scalp. These are shampoos that contain one or more active ingredients, and some may also contain pharmaceuticals. For this reason, they are not recommended. Similarly, shampoos that contain cortisone should be avoided as they can cause damage to the skin and may negatively impact hair growth. As these shampoos are marketed as being medicated, the individual often believes that by massaging the product into their scalp and leaving it for the active ingredient to start working, they will improve their psoriasis. In fact, the opposite occurs, with surfactant irritation aggravating any symptoms of itching, flaking and the psoriasis itself.

he shampoo recommended by DermaClub

DermaClub suggests the use of Dermictiol Shampoo, which is formulated with non-foaming surfactants that do not irritate the psoriatic scalp.

It also contains ichthyol sulfonate, a natural anti-inflammatory.

Even with Dermictiol Shampoo, it is important to wash the hair without massaging the product into the scalp and to rinse immediately.

Psoriasis of the nail

Nails affected by psoriasis suffer the same changes in the stratum corneum.
In a psoriatic nail, the laminae that make up the nail become detached from each other, causing the affected area to become detached from the nail bed. This causes the nail to become brittle, opaque and to change color, as well as becoming permeable to external agents such as water, detergents, dirt and microorganisms. For reasons that aren’t perfectly clear, when more than one nail is affected by psoriasis, a diagnosis of nail mycosis is made. With this diagnosis, the patient is usually prescribed antifungal treatments (in the form of nail lacquers or oral antifungal drugs), however these do not cure the underlying psoriasis and only delay correct diagnosis and treatment.

The changes caused by nail psoriasis can cause particular discomfort, especially to the fingernails.
Nail psoriasis can also cause deformities of the distal phalanges of both the fingers and toes.

Psoriasis on the body

Topical pharmaceuticals, including those with cortisone, have little effect on the course of nail psoriasis. This is because the infected part of the nail is the nail matrix, and not the lamina. The matrix lies beneath the skin, before the nail plate and is practically inaccessible to the aforementioned treatments.

DermaClub recommends

DermaClub suggests treating psoriatic nails with 2S Cream. This natural reducing agent should be massaged into the entire nail contour each evening, with special attention paid to the area between the lamina and the nail bed by the free edge of the nail. Avoid getting nails affected by psoriasis wet. The condition of psoriatic nails can be improved greatly through responsible sun exposure. In the summer, it is therefore recommended to expose the nails to the sun and, if the toenails are affected by psoriasis, to wear open-toed sandals.

Psoriasis on the body

Psoriasis can appear in various forms and areas of the body. The most common form is plaque psoriasis and the most commonly affected locations are the elbows, knees, and sacral area. Psoriasis can, however, appear in a polymorphous manner with:

• small but clustered plaques
• even smaller, scattered plaques (teardrop or guttate)
• a single patch or plaque
• large plaques in abstract patterns

Looking at a psoriasis plaque under magnification, there is a clearly demarcated inflammatory base covered with a mixture of partly-adherent, partly-raised and partly-detaching squamous membranes. Together, these form micro-cracks that intertwine with each other.

• In this plaque, there is little, if any, of the flexibility that is typical of the stratum corneum, which causes micro-cracking to form with each movement.
• The skin’s Barrier Function is altered so water, detergents, dirt, and microorganisms can penetrate the plaque.
• The inflammatory state of the plaque illustrates the stressed condition of the living cells that are no longer protected by the stratum corneum.

It is therefore important for those with psoriasis on the body to shower quickly, using lukewarm water and Eudermic Cleansing Base, a non-foaming cleanser that maintains hygiene while minimizing irritation from washing.

Psoriasis on the body: the job of natural reducing agents

Natural reducing agents suitable for the treatment of psoriasis are:

• sulfur
• salicylic acid
• ichthyol sulfonate
• coal tar

DermaClub recommends: treatment for plaque psoriasis

2S Cream should be applied directly onto every individual psoriasis plaque each evening and massaged until fully absorbed. In the morning, apply PEG Ointment to the plaques to protect and soothe the skin throughout the day. In some cases, 2S Cream may be substituted by coal tar cream, which also effectively reduces psoriasis. Coal tar is not sold in all countries, but is commercially available in countries including the UK, Ireland and the USA. It may also be available online or prescribed by some dermatologists who will prepare it for patients. It is important to note that coal tar is a strong photosensitizer, meaning it causes an increased sensitivity to light. For this reason, it should only be used between October and March.

Palmar psoriasis

Plantar psoriasis

Palmoplantar psoriasis

What to do in cases of palmoplantar psoriasis

As its name suggests, palmoplantar psoriasis can affect both the palmar and plantar. At times, this psoriasis may only affect either the palmar or plantar region at a time. The most common form of palmoplantar psoriasis causes hyperkeratosis (the thickening of the stratum corneum), which often results in cracking. To reduce palmoplantar psoriasis, DermaClub recommends the application of 2S Cream every evening. In some cases, this may be substituted for coal tar cream. In the morning, the anti-inflammatory PEG Ointment should be applied to protect the skin throughout the day. Avoid washing the affected area as far as possible, so as not to cause irritation from water and detergents. If necessary, use nitrile gloves to cover the hands to protect them from water.

Palmoplantar psoriasis and dyshidrosis

Often, psoriasis on the hands and feet is dyshidrotic, a condition that is therefore referred to as palmoplantar dyshidrotic psoriasis.
Alongside the usual symptoms of psoriasis, such cases also cause vesicles or pustules to appear in the palmar and plantar sites, causing lesions that are usually very itchy.
Like palmoplantar psoriasis, palmoplantar dyshidrotic psoriasis should be treated with 2S Cream or Coal tar cream in the evening, followed by PEG Ointment in the morning.