Psoriasis

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Overview

Psoriasis is a chronic dermatological disease that causes a rapid and exaggerated growth of the skin cells, having as a result the appearance of some skin plaques which are thickened (hyperkeratotic), white. These lesions can vary in size and their location is mainly on the knees, elbows, scalp, hands, legs and the sacral region (lower back). Psoriasis is more common among adults, but it can occur among children and adolescents as well.
Normally, the skin cells grow and mature gradually, over a 28 day cycle (cellular turn-over), being then replaced by other young cells. The old cells in the superficial layers of the skin are replaced gradually with other new cells from deeper layers. The cells of the superficial layers of the skin die and gradually fall off along with daily activities (bathing, wearing clothes). In psoriasis, the cells do not mature enough, but they quickly migrate to the superficial layers of the skin (in 3-6 days) and form at this level lesions characteristic of the disease (hyperkeratotic plaques).
 


Causes

The exact etiology of psoriasis is not known. Most specialists say that the disease has a genetic determinism (it is inherited). Approximately one third of people with psoriasis have at least one family member (blood relatives) with this disease. However, it is unclear whether genetic factors act on their own in causing the disease or if there are also other personal or environmental factors that have a role in triggering the disease. Psoriasis is not an infectious and contagious disease, so it can not be transmitted from person to person.
Specialist believe that the immunological factors (the immune system) have a role in causing psoriasis, given the fact that in this disease, the abnormal skin layers (hyperkeratotic plaques) and a large number of leukocytes (white sanguine cells, involved in mediating the immune response) may emphasize. Another argument for the immune etiology of the disease is that the disease responds to the immunosuppressive treatment (which inhibits the immune system).
Many factors were involved in the etiology or worsening of psoriasis, some of them are:
- Cold and dry climate is a factor that can aggravate the specific symptoms of psoriasis. The warm, wet climate and the sun (UV) on the other hand can improve the symptoms of the disease
- Skin lesions, regardless of their location, can cause the formation of hyperkeratotic plaques. The most common are the injuries occurring in the ungual and periungual region
- Stress and anxiety can cause the development of psoriasis and may also aggravate the existing injuries
- Infections, especially throat infections (pharyngitis, tonsillitis), may cause psoriasis (by different immune-mediated mechanisms). This is especially common among children infected with streptococcus
- Certain drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs), beta blocking agents (drugs used to treat heart diseases and hypertension) and lithium salts, can aggravate the symptoms of psoriasis. It is very important that people with psoriasis should consult a doctor before taking these drugs.


Symptoms

The specific symptoms of psoriasis are hyperkeratotic skin plaques, shiny, red and raised skin lesions, predominantly located in the elbows and knees. There are several types of psoriasis, so that symptoms vary in severity and complications from case to case.
The most common symptoms of psoriasis are:
- Red and raised (skin plaques) skin areas, with glossy crusts at the surface. The skin plaques may have different locations, but most often they are found on the elbows, knees, scalp, hands, legs and the lower sacral region. About 90% of people with psoriasis have such skin lesions
- Small, bleeding areas which are the result of the peeling of skin lesions (called Auspitz’s sign)
- Thin or thick crusts located on the scalp
- Pruritus (itching), especially in later stages of the disease, mostly in the lesions located on the skin folds (under the breasts, the armpits, buttocks)
- Nail changes are found in about 50% of patients with psoriasis.
Some of these nail chages are:
- Small, ungual and periungual spots (without the evidence of a fungal infection-onychomycosis)
- Yellowing of the toenails and very rarely, of the fingernails
- Separation of nail from the nail bed (from the root)
- Very rarely, fine subungual deposits of skin tissue.
Other symptoms, rarely found in people with psoriasis, are:
- Skin plaques located in the mirror (bilateral, e.g. both elbows or knees)
- Skin lesions similar to water droplets. This type of injury is most common in psoriasis which is secondary to a pharyngeal streptococcal infection and it is called gouty psoriasis. This type of psoriasis is encountered in about 10% of all cases of psoriasis
- Arthralgia (joint pain), arthritis with joint stiffness (swelling of the joints with reducing their mobility) and periarticular edema. This type of psoriasis is called psoriatic arthritis and it is encountered in 5-10% of all people with psoriasis.
The Koebner phenomenon may occur in some people with psoriasis who have suffered from an injury (burn, excessive exposure to sunlight, cut) in a skin region not affected by psoriasis. This phenomenon consists of the appearance of some characteristic psoriatic lesions, at about several days to 2 weeks after the acute injury. Since this phenomenon is frequently encountered in medical practice, people with psoriasis are advised to avoid as much as possible skin injuries and excessive sun exposure.
It should be mentioned the fact that there are several dermatologic diseases which have symptoms and skin lesions similar to those occurring in psoriasis. Also, some medications can cause skin reactions (red, thickened skin), similar to the skin plaques in psoriasis.


Physiopathogenic mechanism

Psoriasis is a chronic disease, with relapses and exacerbation ( episodes of the worsening of the disease which are repeated at a certain interval) and whose evolution can be unpredictable. The symptoms of the disease can appear suddenly and in the same way they can improve or disappear (remission). This cycle of exacerbations followed by remissions, continues all life. Rarely, psoriasis may go away without performing any treatment. Moderately severe and severe forms of psoriasis should be appropriately treated in order to ameliorate symptoms and prevent complications. There are many factors that can worsen the disease and cause relapses. Some of them are: cold and dry climate, stress, infections, skin lesions and the use of certain medicinal substances. The severity of the disease is indicated by the number of lesions and their characteristics (redness, thickness, exfoliation), as well as by the body surface affected by the hyperkeratotic skin plaques. The mild forms of the disease (affecting less than 3% of the body) are characterized by skin lesions (plaques) located just on the elbows and knees.
The moderate forms of psoriasis have the following symptoms:
- Some skin plaques of a medium size (usually, over 80% of the scalp is affected)
- Skin plaques can cover up to 10% of the body surface ( the equivalent of the skin of both upper limbs)
- Arthralgia (joint pain), without functional impotence
- Cosmetic discomfort (a complex about the appearance of skin lesions).
The severe forms of psoriasis have the following symptoms:
- Skin plaques covering large portions of the skin (20-30%). In order to calculate the body surface, it must be mentioned the fact that the palm equals 1% of the total skin surface and that each upper limb is about 10% of this surface
- Skin plaques located on the face
- Pustular skin lesions (raised skin lesions, filled with liquid) or the appearance of erythrodermic psoriasis with severe inflammation and massive exfoliation of the skin
- Psoriatic arthritis, which involves the inflammation and swelling of joints with pain, functional impotence, redness and local warmth. The severe forms of psoriatic arthritis can cause even bone destruction.
Psoriasis may persist for a longer period of time without worsening or improving symptoms. The disease can cause mental stress and anxiety, as well as the appearance of a cosmetic complex. Some studies have shown that some patients with psoriasis show a mental and functional impairment similar to that of patients suffering from other serious diseases like cancer, chronic arthritis, depression or heart diseases. Sometimes it is necessary to associate the medication used in the treatment of psoriasis with psychotherapy.
 


Risk Factors

Most specialists believe that psoriasis is an inherited disease ( with genetic transmission). It is known that some people who carry the mutant genes for the disease have a risk 10 times higher for developing the disease. A third of the people with psoriasis have at least one family member with this disease.
There were many factors which were involved in the etiology or worsening of psoriasis. Some of these factors were mentioned above.
Another risk factor for the development of psoriasis is the exaggerated consumption of alcohol. It turned out that alcoholics, usually develop a more severe form of psoriasis compared with people who do not consume alcohol. This form of the disease is more common among middle-aged men, big consumers of ethanol. However, it was not proven yet the relation between alcohol consumption in women and the emergence or worsening of psoriasis.


Consulting a specialist

It is necessary to consult a specialist if these symptoms occur:
- Appearance of erythematous (red), raised (plaque) areas, covered with a shiny crust that exfoliates
- Crusted plaques appeared on the scalp
- The yellowing or presence of some spots on the nail, the separation of the nail from the nail bed or the appearance of some deposits of skin tissue at this level
- Signs of a possible bacterial infection (the infection of skin lesions), such as:
- Accentuated pain, swelling, erythema (redness), increased local sensitivity or warmth
- The occurrence of thin, reddish lesions in the skin plaques
- Presence of pus
- Temperature higher than 38 degrees C, without other known cause.
In the case of people diagnosed with psoriasis and treated accordingly, it is necessary to consult a specialist when the following symptoms occur:
- Lesions extended on a large area of skin, their accentuated swelling, especially if the patient has another disease as well
- Appearance of symptoms as side effects of drug treatment of psoriasis (vomiting, sanguinolent diarrhea, chills or fever).


Watchful waiting

It is important that all people who develop skin lesions associated with psoriasis consult a specialist dermatologist. The initiation of treatment in an early stage may slow or stop the progression of the disease.


Symptoms

Recommended medical specialists
Healthcare workers who can diagnose and treat psoriasis are:
- GP
- Dermatologist
- Doctor of internal medicine
- Rheumatologist.


Investigations

In most cases, the diagnosis of psoriasis is given by the dermatologist after the physical examination (inspection of skin lesions) that reveals edematiate and erythematous skin plaques (red). Lesions characteristic of the disease are raised, reddish skin changes, covered with a glossy layer (hyperkeratotic plaques) prone to exfoliation, especially located on the elbows, knees, scalp, hands, legs and the lower part of the back (the sacral region). Special tests are no usually needed in order to confirm the diagnosis of psoriasis. If it is still necessary to confirm the diagnosis, your dermatologist may perform a skin biopsy for the laboratory analysis of the lesion in question. If there is a damage of the joints, a bone radiography may be necessary to identify the specific changes of arthritis (gouty psoriasis). Blood tests may be useful, especially for the differential diagnosis with other types of arthritis.
Gouty psoriasis is a rare form of psoriasis. Lesions characteristic of this type of psoriasis are the presence of circular, oval, raised (papules) skin changes, which occur mainly on the trunk and less on the limbs. In this case, it is possible for you dermatologist doctor to perform a puncture and a culture at this level, to search for a possible streptococcal bacterial infection. Very rarely, a test with KOH (potassium hydroxide) is needed in order to exclude a possible fungal infection (fungal).


Treatment – Overview

It is known that there is currently no cure (curative treatment) for psoriasis. On the other hand, there are several types of treatment that can relieve symptoms, such as special ointments, phototherapy or oral medications. Most cases of psoriasis are mild and require no treatment except for the use of certain ointments (topical treatment). Severe forms are difficult to treat and often require the administration of oral medication. Psoriasis, regardless of the type, is a relapsing disease (returns after e period of time).
The goal of the treatment is to reduce the accentuated rise of the skin tissue (plaques) and the inflammation secondary to it. The treatment of psoriasis is performed depending on the type and the severity of the disease (depending on the location of skin lesions, their expansion and complications, the associated diseases). Besides the physical component (skin, joint damage), it should be taken into consideration also the psychiatric component (depression, frustration secondary to the unpleasant appearance), so that in some cases, the psychiatric treatment may be needed (psychotherapy, antidepressant medication).

 


Initial treatment

The treatment for mild psoriasis (skin plaques limited to some isolated body regions, without complications), starts with the use of some specially created creams to keep skin soft and moisturized. Most products used to treat mild psoriasis can be purchased without a prescription and are administered with no special problems:
- Creams, lotions, ointments, used for a proper hydration of the skin
- Shampoos, oils, sprays, used to treat psoriatic plaques appeared on the scalp
- Ointments, to treat psoriatic nail lesions
- Limited exposure to sunlight.
The prevention of the aggravating factors of psoriasis is very important. Some of them are:
- Avoid stress
- Avoid skin injuries as much as possible, especially burns (including sunburn)
- Avoidance and proper treatment of infections (pharingeal, tonsil or lower respiratory tract infections, pneumonia with streptococcous which can cause gouty psoriasis)
- Reducing alcohol consumption
- Rational use of medicinal substances (non-steroidal anti-inflammatory drugs, beta-blocking agents or lithium salts, which can aggravate the symptoms of psoriasis).


Maintenance treatment

Some ointments and creams may be used alone or in combination with phototherapy (ultraviolet therapy) in the maintenance treatment of mild, uncomplicated psoriasis (with skin lesions spread on less than 20% of the total body surface). It must be mentioned the fact that the local treatment (topical), such as ointments, creams or lotions, is more effective in some cases than in others. If symptoms do not improve after the administration of the local treatment, your doctor will choose another treatment or a combination of several treatments. If the treatment involves phototherapy (brief exposure to ultaviolete B,rays known as UVB), specialized medical surveillance is necessary in order to avoid possible adverse reactions that can occur secondary to the use this type of therapy (lesions , skin burns).
Exposure to ultraviolet rays (UVB phototherapy) is often used to treat psoriasis and it has good results in relieving the symptoms of the skin. Phototherapy is used in certain doses, 3 times a week, often in combination with a topical treatment (tar or calcipotriene) and it is extremely well tolerated by most patients.
A combination between phototherapy and ultraviolet A and Psolaren (PUVA – psoralen combined with ultraviolet A) is also used to treat psoriasis and it has beneficial effects. There are certain medicinal substances, photosensitzers, such as methoxsalen, which can be administered orally or topically (creams), before exposure to UVA. The treatment is performed 2-3 times per week and most patients obtain an improvement of their clinical status (decrease, disappearance of skin plaques), after about 19 to 20 sessions of phototherapy.
The topical medication used to treat psoriasis, includes the following agents which can be found in various lotions and ointments:
- Compounds of vitamin D, such as calciferol
- Topical medication with costicosteroids (substances with powerful anti-inflammatory effect)
- Retinoids, like tazarotene
- Certain types of tar and anthralin.
The treatment for psoriasis by body wraps consists of the local administration of some ointments, gels or lotions, with powerful mosturizing effect, then that area is wrapped with plastic or material foils. This type of treatment helps to maintain an adequate hydration and increase the effectiveness of the topical treatment.
The biological medication consists of a relatively new treatment that uses drugs such as alefacept and efalizumab, which have as an effect the selective blocking of the immune response with an important role in the occurence of lesions specific to the psoriatic disease.


Treatment if the condition gets worse

If psoriasis is severe (skin lesions – the cutaneous hyperkeratotic plaques cover more than 20% of the body surface area), your dermatologist will recommend the establishment of a systemic drug treatment. This includes oral administration of retinoids, methotrexate (immunosuppressive drug) or Cyclosporin (immunosuppressive drug) in combination with the topical treatment (ointments, lotions, creams or exposure to ultraviolet rays).
There is a certain resistance to the use of the systemic drug therapy among children diagnosed with psoriasis, because there are not sufficient scientific arguments sustaining that this type of therapy has notable benefits at this age. Children have a reduced tolerance to the administration of immunosuppressive medication and side effects are frequent and have a relatively high gravity. In some less frequent cases, drug substances can be administered by subcutaneous injections or by using transdermal patches (gradually release the active drug substance which is absorbed from the skin). The treatment for psoriasis can last all life, so that sometimes psychological counseling helps to relieve symptoms and offers the necessary psychological support.
Keep in mind!
It is possible for patients diagnosed with psoriasis to try several types of treatment till they find the most effective treatment in treating the disease, this is the reason why it is important for each patient to perform regular specialist medical checkups in order to find the most effective treatment. A recent study showed that proper education, stress reduction and muscle relaxation techniques can bring a certain benefit among people with psoriasis. Those therapeutic factors combined with the initial treatment plan can achieve a significant reduction in discomfort, anxiety and stress, associated with the evolution and treatment of the disease.
The treatment for psoriasis has in some cases also certain side effects. People with severe or complicated psoriasis may require a long term treatment long, sometimes for the entire life. Therefore, regular medical examinations are recommended in order to overcome these undesirable effects and eventually to change the treatment with a better tolerated one.


Prophylaxis

There is no way to prevent psoriasis. However, there are certain factors that can alleviate symptoms and reduce its complications. Some of them are :
- Maintaining a proper skin hydration (by using lotions, creams or gels with higher skin absorption)
- Avoid cold and wet climate. Cold weather may worsen the symptoms, while hot, humid and sunny weather can improve symptoms. However, it must be mentioned the fact that some types of psoriasis may be aggravated by hot and humid climate
- Avoid as much as possible skin injuries, scratching and the early separation of post-traumatic crusts. Any skin lesion can cause the appearance of hyperkeratotic skin plaques at the place of the injury or at distance from it. Among the most common injuries are the ungual and periungual changes occurring secondary to an improper manicure (repeated trauma to the nail bed – nail root)
- Avoid stress and reduce anxiety, because these psychic factors can exacerbate the symptoms of the diseaase and cause the appearance of new skin plaques. It must be mendtioned the fact that this has not been proven by specialized medical studies
- Prevention of infections, especially throat and tonsil infections with streptococcus, which can cause gouty psoriasis. This form of psoriasis is the most common among children
- Cautious use of certain drugs. Some medicinal substances are contraindicated to patients with psoriasis (beta-blocking agents, lithium salts and nonsteroidal anti-inflammatory drugs can worsen symptoms). People with psoriasis should mention the presence of this disease every time any treatment with medications must be established.
- Reducing or quitting drinking, because the excessive consumption of ethanol can worsen the symptoms of the disease, especially for middle-aged men.


Home Treatment

Home treatment improves the symptoms of psoriasis. This involves the regular use of ointments, lotions, bath oils, shampoos and special soaps. UVB (ultraviolet B rays) therapy is also indicated by using special lamps that can be used also at home.
A proper skin care includes the following:
- Proper care of the skin by keeping an appropriate hydration, applying creams and lotions with a high water content
- Remove the crusts of the skin plaques carefully, avoid of skin lesions. The adequate hydration of the skin plaques is recommended before removing the psoriatic crusts at this level. A special attention is needed when removing the crusts of the skin, in order to avoid erosion, increased inflammation and edema at this level
- Read carefully the instructions for the use of cosmetics or drug treatment for psoriasis and other diseases. Most times it is necessary to use several topical products till it is found the most appropriate for each case. In the case of people with uncomplicated, easy psoriasis, it may be useful also the use of certain products that can be purchased without a prescription, such as lotions with aloe vera
- Conducting a regular and rational treatment of exposure to ultraviolet (UVA or UVB)
- Specialized medical checkups performed regularly or whenever there are changes in the disease.
Further useful information in order to treat psoriasis:
- Adequate protection of the skin by treating the infections that can occur at this level (especially on the skin plaques), avoid injuries or irritation of any kind at this level
- Proper care of the scalp with regular use of special shampoos. We must remember that patients with psoriasis must treat the scalp, not the hairs in order to stop hair loss
- Proper nail care, especially the nails of the hands, avoid aggressive manicure techniques that can favour the emergence or worsening of lesions characteristic of proriasis
- Avoid excessive exposure to sunlight. Although short and rational exposures to sunlight (a few minutes between 7 am and 10 am or 5 pm and 7 pm) improve symptoms, excessive exposure can cause irreversible damage to the skin and cancer (throudh sunburn and excessive exposure to the UV). Sunburn can worsen the evolution of psoriasis
- Avoid the use of certain drugs that may worsen the symptoms of psoriasis (nonsteroidal anti-inflammatory drugs, lithium salts or beta-blocking agents).
There are no medical studies that prove the benefits of some nutritional factors (diet) in the prevention or worsening of psoriasis. However, a balanced diet, low in lipids (fats) and keeping a normal weight can bring some benefits in the evolution of the disease.


Medication

Medication
In psoriasis, the topical treatment is used alone or in combination with the systemic drug therapy. The local treatment is reserved for mild, uncomplicated cases, in association with phototherapy (exposure to ultraviolet type A or B rays). More rarely, the subcutaneous injection of certain medicinal substances or the use of special patches (transdermal patches) is possible.
It is useful to carefully remove the crusts of the skin plaques after soaking the skin in advance with a moisturizer. This procedure must be carefully performed and it is performed by esily massaging the exfoliated skin plaques and avoiding injuries at this level (cosmetic peeling). The exfoliation technique is performed gradually, avoiding the mechanical irritation of the areas in question. Psoriasis affecting the scalp or the nail region can be difficult to treat and it is preferable to administer oral medication. The cutaneous plaques appeared on the scalp can be treated by applying special shampoos, oils or products containing selenium sulfide or zinc. When using topical or systemic treatments for psoriasis, it is necessary to perform some specialized medical checks in order to identify any adverse reactions or the appearance of skin cancer (those with psoriasis are more likely to develop skin cancer). Sometimes, it is advisable to periodically change the treatment, so as to reduce the risk of unpleasant side effects.


Wrapping technique

This treatment uses the previous use of moisturizing creams and lotions, so that the skin can be then wrapped in a thermoinsulating layer of plastic or other special materials. This technique is useful in some cases because it is relatively easy to perform it and helps the medicinal substances get into the skin. This treatment method can also use ointments containing corticosteroids in more affected areas (but not on large areas). Wrapping technique, excessively used on extensive body areas, can lead to the thinning of the skin, making it more exposed to injury and sunburn.


Medication Choices

The topical medications (with local administration), used to treat patients with psoriasis, include the following:
- Corticosteroids, most often used for the local treatment of psoriasis
- Calciferol, a compound of vitamin D3
- Retinoids, the most often used being Tazarotene and Acitretin
-tar and anthralin, gradually replaced by other treatments such as calciferol and tazarotene
- Zinc pyrithione, a new product that is found in the form of spray, soap or lotions. It is used to treat small skin plaques and it is very effective in relieving some symptoms such as pruritus (itching), hyperemia (redness) or excessive exfoliation of the skin. It is also used successfully in order to treat psoriasis affecting the scalp. Although until now there are few medical studies proving the effectiveness of zinc products, some patients with psoriasis report the improvement of their symptoms or even the disappearance of skin plaques.
The oral medications include:
- retinoids
- Cyclosporine
- Methotrexate.
Methotrexate and cyclosporine are two immunosuppressive drugs (suppress the immune system) and are used only in severe forms of psoriasis, due to the severe adverse effects (infection, the appearance of tumours).
Generally, the treatment for psoriasis begins by using topical products (corticosteroids, calciferol or tazarotene). These drugs may be used alone or in various combinations. In some cases the medication may not have the desired effect, so that phototherapy with ultraviolet A rays (PUVA) can be tried. Also, if the topical or systemic treatment does not improve symptoms or psoriasis worsens, you can try taking cyclosporine. There are several combinations of treatments with good results, of which we mention those most commonly used in medical practice:
- Psolaren and phototherapy with ultraviolet A rays (PUVA)
- Tar and phototherapy with ultraviolet B rays (Goeckerman treatment)
- Anthralin and phototherapy with ultraviolet B rays (Ingram regimen).
The treatments with a proven efficiency in psoriasis include the following:
- Calcitriol (vitamin D derivative)
- Phototherapy (especially PUVA)
- Ingram regimen.
Although the topical treatment with corticosteroids is effective in most cases, its misuse can worsen the local symptoms. There are several new drugs approved by the Food and Drug Administration and which are successfully used in treating psoriasis.
The biological treatment includes some substances that can be injected and selectively modify the response of the immune system (responsible for the disease). There are currently several medical studies proving the effectiveness of this new type of treatment in hte psoriatic disease.
Some of these drugs are:
- Alefacept, efalizumab and Etanercept, which were approved by the Food and Drug Administration for the treatment of moderate and severe psoriasis
- Etanercept, Infliximab (Remicade) and Adalimumab are approved for treating psoriatic arthritis
Keep in mind!
People with psoriasis react differently to treatment. A treatment that has proven to be effective for a period of time may not have the desired effect after a period of time and in the same way a treatment that did not work at first, may be able to improve symptoms if used again after a certain time. Most drugs with systemic (oral or injectable) administration have serious side effects such as liver and kidney toxicity, development of tumors (cancers). It is very important for your doctor to weigh the benefits and disadvantages of any treatment, in order to avoid such unwanted side effects.
Any person with psoriasis must establish together with the doctor the approximate duration of the treatment and the most effective form of treatment (relief of symptoms and avoidance of the appearance of adverse effects) for each case. Regular health checks and blood analyzes that can reveal the occurrence of complications related to the treatment are recommended. Many drugs that are used to treat psoriasis can not be administered during pregnancy, because they are teratogenic (can cause abnormalities of the fetus or miscarriage). Any woman with psoriasis who wants a child, should consult the doctor before getting pregnant.
We must not forget that some drugs used to treat psoriasis inhibit the immune system and can cause serious diseases like cancer.


Surgical treatment

Surgery is rarely used in psoriasis. Surgery is useful in cases where there are serious injuries, occurred in the nails. In this case the surgical excision of the nail can be performed.


Other treatments

Ultraviolet phototherapy is useful in treating psoriasis. If this method is used, the patient must be checked by a dermatologist in order to rule out the occurrence of malignant skin lesions (it is recommended at least 2 times per year).
There are several types of complementary therapies used to treat psoriasis.
These include:
- Plant extracts
- Vitamins
- Special diets
- Methods of reducing stress
- Climatotherapy (reasonable exposure to sun and sea water).

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