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psoriasis

AUTHOR: Marc Mitnick DPM

REVIEWED BY: Podiatric Medical Review Board

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WHAT IS PSORIASIS

This is mainly a skin condition marked by patches of thick, red skin covered with silvery scales that occur primarily on your elbows, knees, legs, lower back, scalp and feet. Certainly not life-threatening, the condition can be painful, affect your ability to function, and cause psychological and emotional distress. Approximately one third of patients with this condition have a family history of the disease.

This type of eczema affects two to three percent of the Caucasian population which includes over seven million Americans with an estimated 125 million world-wide suffering from this affliction. This condition is seen less in African-Americans along with Asian and Eskimo populations. It is virtually unheard of in Native Americans. This condition is seen more in northern exposures as opposed to southern altitudes where people have greater sun exposure.

This dermatitis develops when the ordinary life cycle of skin cells accelerates. Skin cells regularly die and flake off in scales — but in people with psoriasis this process happens within days rather than weeks. Rounded, circumscribed, red, dry, scaly patches of varying sizes characterize the skin. Itching and burning may also be present. On removal of the scaling skin bleeding points occur known as Auspitz’ sign. Koebners’s phenomenon is also frequently found. This is the appearance of typical psoriatic lesions at the site of an injury.

types of psoriasis

• seborrheic which is the most common form.
• Inverse, seen more commonly in overweight people characterized by smooth patches of red, inflamed skin. Friction and perspiration cause it to worsen.
• Guttate, which primarily affects people under the age of 30 and is generally caused by a bacterial infection.
• Pustular, is very common on the feet but overall is rare. It occurs quickly, forming pus filled blisters which will dry out rapidly but then quickly reappear. When it occurs all over the body it can produce fever and chills.
• Erythrodermic, is the least common form which may be triggered by sunburn or medication. This can cover the whole body with a red peeling rash.
• Psoriatic arthritis, in addition to the skin reaction the joints may also be affected in the same way that arthritis affects the joints. Symptoms range from mild to severe. It may lead to permanent deformity but generally speaking is not as severe as other forms of arthritis .

The disease is chronic, but you may have periods when the condition becomes worse alternating with times when it improves or goes into remission. And although no cure exists, treatments may offer significant relief.

factors predisposing you to psoriasis

Aside from a positive family history being a risk factor for psoriatic conditions, other factors include stress which can have a negative impact on your immune system. Medications particularly beta blockers can predispose someone to this condition. Even lithium may make you more prone to pustular eruptions. Excessive exposure to sun can exacerbate the eczema, while small amounts of exposure to the sun may actually help the condition. People with HIV and children with frequent recurring infections may also be more prone to this type of eczema.

Below is a picture of a typical psoriatic eruption on the bottom of the feet.

About 50 percent of patients with psoriatic eczema eventually develop the condition in the nails of the hands and feet. The classic changes seen within the nails is pitting of the nail plate. This is the result of damage directly to the nail matrix (growth plate of the nail). Other nail changes commonly seen in psoriatic nails include yellow discoloration of the nail plate along with detachment and crumbling of the nail and the accumulation of thick tissue under the nail. These nails may appear very similar to mycotic (fungus) nails.

Below is a picture of a psoriatic nail.

psoriatic arthritis

This is another aspect of this disease state that commonly manifests itself in the feet. Approximately 5-7 percent of those suffering from psoriasis will eventually develop arthritis. Men and women are affected equally. The peak incidence is in the fourth to sixth decade.

There are no specific laboratory findings in psoriatic arthritis so the condition has to be differentiated from other arthritides such as osteoarthritis, rheumatoid arthritis, and goutl . When a patient presents with the cutaneous manifestation of psoriasis the diagnosis is easy; it is more perplexing when there are no cutaneous or nail lesions (and no history of the actual disease).

Clinically in the foot psoriatic arthritis has certain characteristics. One is diffuse swelling of one or more toes commonly known as “sausage digits”. This is thought to be due to a combination of swelling from both arthritis and tenosynovitis.

Note the "sausage" appearance of some of the toes.

Although there are a number of skeletal manifestations of the disease the picture below notes the classic findings of psoriatic arthritis in the foot. The blue arrow points to a normal even joint space between the second metatarsal bone and the second toe. Notice the red arrow; that is a classic “cup and saucer” effect of the fourth metatarsal bone being jammed into the base of the fourth toe. The yellow circle shows the destruction in the toes that is characteristic of the disease. This destruction has occurred on the other toes as well.

TREATMENT OF PSORIASIS

topical medications for psoriasis

Treatment for psoriasis is geared to reduce inflammation both in skin and bone manifestations. Since statistically most people who suffer from psoriasis suffer primarily skin eruptions topical medication is usually the treatment of choice.

• Hydrocortisone cream has always been the old standby. These creams not only cause an immune suppression but they are also anti-inflammatory. Chronic use of topical cortisone cream will have a tendency to thin out your skin. Another problem with cortisone cream is a condition known as tachyphylaxis, this is a situation where the patient has been using a topical cortisone cream for some time and all of a sudden it stops working. The patient may then try another topical steroid cream which initially will be beneficial, but then it too stops working. This can be very frustrating for the patient and the treating doctor. For this reason if you should start in with another doctor for your psoriasis, it is very important that you let he or she know what medications you have previously tried.
• Anthralin is a topical prescription medication that when properly used may send your psoriasis into remission for upwards of six months. It is messy to use and may stain clothing.
• Vitamin D Analogs may be used alone or in combination with topical cortisone creams. The vitamin D analog helps decrease inflammation and reduce plaque appearance. Tachyphylaxis does not appear to be a problem with this medication. Used in combination with a topical cortisone cream, it will reduce the side effects of the steroid cream. One such medication is Dovonex. It works by slowing down skin cell turnaround time which prevents formation of skin patches. Other medications in this class include Vectical, Galderma and Taclonex.
• Coal-tar ointments have been used for psoriasis for ages; they are sold over the counter in 1-5 percent strength. They are generally inexpensive but they are also greasy, messy to use, have an odor and are staining. They may also cause sensitivity to sunlight. A prescription item, Scytera foam was developed to decrease the greasiness and odor of traditional tar preparations. Coal tar preparations traditionally reduce inflammation and pruritus (itching).
• Tazorac is another medication, which seems to prolong psoriasis remissions. It is particularly helpful when used with moisturizers and ultraviolet light therapy. This medication is a synthetic retinoid that has an anti-inflammatory component. The drawback to this medication is that it can be extremely irritating to the skin. Since this medication needs to be applied directly to the psoriatic plaques, it can be helpful to apply vaseling on the healthy skin to avoid irritation. Another trick is to start using the medication every other day until it becomes tolerated.
• Keratolytics include urea, salicylic acid and lactic acid creams. These medications help remove excessive scaling. It may be used in conjunction with topical cortisone cream; the idea being that it enhances the penetration of the cortisone cream. But, with greater absorption comes the potential for more complications. These medications may also be used on psoriatic nails in an effort to thin them out.
• Moisturizers include over the counter emollients like Eucerin or Curel cream or even prescription emollients. They work by restoring the function of the epidermal (skin) barrier, decreasing water loss and improving the appearance of the skin. These emollients are best applied immediately after a bath or shower as they are better absorbed on moist skin. They too, may be used in conjunction with topical cortisone cream.

other treatments for psoriasis

• Ultra violet light has been used with success in psoriasis treatment as either ultraviolet B phototherapy or a photochemotherapy using ultraviolet light in combination with systemic or topical psoralen, which is a natural occurring compound that enhances the effects of the ultra violet light treatment. One can either soak in a solution containing psoralen or apply a topical cream containing psoralen and then have the ultra violet therapy.
• If you prefer to try some alternative treatments licorice root and chamomile are herbs that both contain anti-inflammatory compounds. Applied topically to the lesions may reduce the skin inflammation. Aloe cream has been shown to be effective.
• Since high protein diets are associated with an increase in inflammation through the body, reducing your consumption of protein rich foods primarily meat and dairy products may reduce flare-ups.
• Fish oil supplements are also known to have an anti-inflammatory effect on the body and therefore may reduce the inflammation of psoriasis. Four to six capsules a day containing EPA and DHA are recommended.
• For those with psoriasis, sunbathing can also be helpful. In a world where everyone is avoiding the sun out of fear of developing skin cancer, the sun’s rays have been shown to have significant therapeutic benefits. Psoriatic patches are far less common in most individuals during the summer months.

oral medications for psoriasis

• For psoriatic arthritis the simplest oral medication is the class of anti-inflammatory medication. This class of medication is reserved for moderate pain associated with the arthritic component of psoriasis. Click here for a recent warning issued by the FDA on anti-inflammatory medication (December 2006).
• In patients with more destructive disease the class of drugs known as DMARDS (disease modifying anti-rheumatic drugs) should be initiated. The most common drug in this class is Methotrexate, (a chemotherapy drug), which has been shown to be effective for both the cutaneous and articular forms of psoriasis.
• Anti-malarials also in this classification has been shown to be of help for both severe cutaneous and articular forms of psoriasis.

  Additional drugs in this class include Sulfasalazine, Cyclosporin A, Etanercept, Remicade and Humira.

  It is important to emphasize that these are serious medications and should not be abused.

See related article......eczema

See related article......nail fungus

REFERENCES

Mayo Clinic

Centers for Disease Control and Prevention

Cleveland Clinic

Want more information? CLICK HERE

ORTHOTICS for multiple types of foot pain best buy in a pre-made orthotic click link below



ORTHOTICS for heel and arch pain for those who must wear dress shoes click link below

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Hunterville, NC

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NY

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NJ

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Fla

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Ontario, Canada

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Fla.

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Judy

(location unknown)

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New York

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Memphis, TN

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Thanks again so much for the information in the article. Very interesting.

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Scotland

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J. Simmons

(location unknown)

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Tennessee

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Redondo Beach, CA

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Thank you for your time and expertise in answering my question…..

LH

(location unknown)

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First, thanks for putting together this website. Its the most informative site I have found dealing with foot problems. Last June I started having pain and swelling at …….

Joe

(location unknown)

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First of all, thank you for having all this useful information available in one place. I've been through most of your website and based on my research, pain and evaluations I think I've narrowed things down quite a bit.

Pete M.

(location unknown)

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Glenda B.

Madison, Alabama

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Thanks for replying so quickly. I was a bit concerned. I think your website is great, and chock full of info.....

Carol

Denison, TX

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Dr. Marc, Thank you so much for your reply which seemed to be right on. I have researched many sites but you put me on the right path to the possible answer. My foot pain may not rule the rest of my life after all! I believe I'll make a sign that reads, "THE END IS NEAR!" Thanks Very Much,

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West lafayette, IN

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Michael E.

Tampa, Florida 33624

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Hi. This is a great site! I'm a healthy middle aged woman who is in good health, but.....

Kelly

Texas

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Just a wee word of thanks for your wonderful website...It is a terrific service...Thank you for providing your knowledge and help...With highest regards, m ebeling

Michael D. Ebeling

Tampa, Florida 33624

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Thanks for a most interesting website, which has helped a lot.

Steve

UK

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Dear Dr.Mitnick

I usually do my research on the Mayo clinic website. I think your website is the most informative site I have found when researching foot pain.

I thank you for putting together this incredible website.

Regards,

Dragica W.

Edmonton,Canada

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South Africa

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You have an unusually clear, informative and well-written website for laypersons. Thank you for that.

Matthew W.

Mansfield Ctr, CT

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First, I'd like to thank you for all the information that you provide on your website and the opportunity to write to you.

Steve

Placentia, California

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First, I want to let you know that you have the best web site I've found related to foot issues. (The only thing I had difficulty finding was the "ask a question" page.)

Unknown

Unknown location

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I received the orthotics Monday afternoon and began wearing them Tuesday. After two days I would say that I have noticed a huge improvement in the discomfort I have been experiencing. My foot feels better than it has in months.

Ric J.

Unknown location

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I greatly admire someone like you who would donate and dedicate so much time and effort to helping strangers with no compensation. Truly, it is uncommonly kind. And your site is so intelligently arranged.

Ron R.

Pacific Grove, CA

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I used to work for a podiatrist (front desk) back during summers in college years ago, so I know the benefits of good care. Again, I want to thank you for an EXCELLENT website. It was so great to get to your site (top of google search) and actually find all the answers I needed EASILY and QUICKLY! Clearly you put a ton of work into it and I really appreciate it.

All the best,

Victoria

Alameda, California

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Anonymous

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Thank you for your very interesting and informative site!

Anonymous

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Hi. I come to your site often looking for information. It is really informative and I appreciate it very much. I have RA and have been having considerable amount of foot pain...... Dee RN

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Thanks very much for the wonderful informative site.

Catherine

New Zealand

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Thank You for my answer! I have been schedule for a bone density scan, allingment, and I am in the process of getting orthotics made, and checking out the natural remedies. Thank again! What a great web site!

Sincerely

Josette

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Yes I want both pair of orthotics. You don't have an option of ordering 2 at one time so I had to place the order twice. Thanks. My husband likes these and wants to put them in all of his shoes. (referring to Superstep orthotics)

Cindy H.

Arizona

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I searched the internet everywhere for a clear description and illustration of my symptoms/problem. https://www.foot-pain-explained.com/ was where I ended my search with answers. If I lived in Jersey (left 30 years ago) and didn't live in Florida I would definetly make an appointment with Dr. Mitnick.

Thanks, Kathy

Florida

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1st of all THANKS A LOT for your great site......

Anna

Poland

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Thank you so much for your response. I will let you know how I am doing if you would like. Your website is awesome!

M P

South Carolina

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Hello! I want to thank you for such an informative website! I found you based on my ankle pain search and am happy to realize that there may be a relatively simple cause and solution....

Natalie

unknown location

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...Thanks for your fantastic service.

Gary

Arlington, VA

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Thank you so very much, that would be much appreciated. I love those insoles, by the way. (referring to Superstep orthotics)

Kelly W.

San Clemente, CA

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Dr Marc is fantastic...He seems to know exactly what you are feeling with the problems you are having. I wish he was in my home town so I could go to him with my problems!!!!!!!!!!!!!

Pam

location unknown

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Great insights! Thanks Doc, you're the best.

Glen

location unknown

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I have been experiencing foot pain of various sorts and am working to figure out what it is. I found this site and can only say BRAVO!! What an excellent site! The time it must have taken to put all this together must've been a daunting task! I am sure it has helped so many people. Thank you so very much for doing this.

Bre

location unknown

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Dr. Mitnick, Thank you so much for your reply. I did let my physician know and they took an x-ray - all is well! Also, thank you for providing this wonderful site, it is very helpful with lots of useful information! I appreciate your gift of time! God bless.

anonymous

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Dr. Mitnick, Thank you, you were 100% correct. The pain finally brought me to the ER. I spent 8 days in the hospital. The Doppler you spoke of was able to show that there was no pulse in that foot. This was an arterial clot that split and traveled throughout my leg. My leg was almost amputated. I am in rough shape but have all my parts intact!! You certainly know what you are talking about. Thank you for taking the time to answer. Yours Truly!

anonymous

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Staying at home after hallux surgery I spend quite a lot of time seaching info useful for avoiding problems which might come back. Today I found your site and I am .... delighted it happened. It's one of the best site I found last days.

Anna

Poland

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Thanks for taking time to read and answer so many questions. It is truly a public service!

Esh

Seattle, WA

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I just wanted to say that I am very greatful for this website!!

Bonnie

location unknown

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Also, and importantly, just want to praise this web site. Thorough and thoughtfully presented, it certainly must be of considerable assistance to anyone with a foot problem. Terrific -- and very interesting.I trust the address comes up easily for those seeking information.

Bill

New Jersey

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Thanks so much for answering my question. You've been more help to me than my own Dr. has been lately. Thanks again....I hope to be able to walk without pain someday.

Debbie

location unknown

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Wow, that is exactly the information needed!!! thank you thank you thank you!!! I appreciate this help so very much from Marc Mitnick DPM. Excellent information and help to improve One's life.

Chrissy

location unknown

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Thanks so much for this website Dr. Marc! It is so nice that you have this ask the doctor feature..I'm sure I'ts been helpful for alot of people. I will try what you suggested and see if it helps...thanks again!

Tracy

Evansville, IA

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Dear Marc

I just want to say thank you for the quick response and the good info. I find it amazing and a super nice thing that you do here by answering medical questions at no charge.

Russ W.

location unknown

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Your website is full of a lot of helpful information, and I am very impressed with the time in which you responded to my post. Thank you again for your time and consideration in your response.

-Sunny.

location unknown

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Thank you very much for the information, I will consider it. Excellent web site.

Jackie

San Diego, CA

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Dr. Mitnick, Just want to say thank you so very much for your quick response and very informative reply! After reading what you had to say, I called the doctor's office and was able to get in and see him the same day as my injury. Toe was x-rayed and luckily, it is not broken or fractured. Very badly bruised and will probably lose the toe nail. And although my toe and toe nail are still very black and blue and very sore, they ARE both starting to feel a little better. So again, thank you! I am so very happy that I came across your website. The service you provide is outstanding and immeasurable!

Rivi,

Albany, NY

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Thank you so much for all of your advice. In searching the web for people dealing with this same issue i can tell you that you are a Knight In shining Armor! If I lived in Jersey I would gladly be your Spokesperson. Hopefully next time you hear from me it will be good news. God Bless,

Jill S.

location unknown

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THANK YOU SO VERY MUCH FOR YOUR TIME AND EFFORTS, YOU ARE SO VERY APPRECIATED. THANK YOU FOR ALL YOU DO.

Jackie

Whichita, KS

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thanks again, this site is very helpful.

mark

Boston, MA

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Like others have stated...This site is amazing and I am so thankful that it was created.

....Keep up what your doing. Your a life saver.

Michelle

Colorado

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Thanks again for the information provided on your site. It's easy for non-medical folk to understand your writing, and helps provide better communication between patient and doctor.

annielou

Colorado

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Wonderful advice

by: Anonymous

This is the best site for foot problem info.

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Thank you for this information. This description fits my pain and inflammation behind my 2nd toe perfectly.

by: Max

location unknown

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Again, I really appreciate that you responded to my inquiry, and that your mention of Parkinson's helped me to find my way to a diagnosis of this difficult to diagnose disease. Most patients see on average 16 doctors before they are diagnosed. I hope that you can help other people that ask for your expertise in the future.

Barb D.

Canada

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I just wanted to say that I am very greatful for this website!! I have had a fusion in my rt foot and am finally getting a little bit better......

Bonnie

location unknown

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Again, Thank you from the bottom of my heart for taking the time to answer my question....your an angel!

Nancie

Wisconsin

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Thank you for your response. You have provided some great insight (to my question)....

Julie

location unknown

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Thank-you so very much for responding so quickly and in such detail to my question!! I will give my surgeon a call today!! This website is terrific!!!! Thank-you again!

Renae

North Carolina

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Many Thanks Dr Marc!
Thank you for your response. It sounds like a good plan to me. He did not cut the wart out first ...

KG

location unknown

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Thanks again doc for having this website and we STILL need qualified Podiatrists in beautiful sunny Tampa Bay (Bradenton) Florida.

Bessie Mae

Florida

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Dear Dr. Mitnick, Thank you so very much for taking your time to answer my question. You have greatly relieved my anxiety related to the continual tingly I feel in my feet. I will share your response with my podiatrist next week. God bless you for having this question and answer page on your website! Most gratefully,

Lynne T.

location unknown

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Your webpage is excellent, I commend you on sharing your knowledge to the public.

Robert

New Jersey

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Thank you. you were more detailed than what others have told me they finally called from the last xrays and my son is now in a cast for 2 weeks he did have a fracture that was not noticeable.

a mom

location unknown

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I have read your website and I have to admit that I am amazed at all the information that is on here. I have learned more than the three years I have been going to several doctors that I have seen!!

Melody

Lenoir, NC

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Thank you so much Doc for a quick and thorough response!

Rustam

Bellevue, WA

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I cannot thank you enough for your response, opinion, and suggestions! I want you to know how much it means to me, and I'm sure everyone else who has ever asked you a question! I feel like you're a lifesaver and have empowered me to take a stronger role and stand up for myself and my feet!

Jodi

location unknown

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