Psoriasis is a skin disorder characterized by itchy, scaly rashes. This skin condition isn’t contagious, though — it’s what’s known as an immune-mediated disease, or a disease occurring when your immune system overreacts and causes inflammation.
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Typically, the symptoms of chronic inflammatory diseases ebb and flow. Psoriasis is similar, says dermatologist Anthony Fernandez, MD, PhD.
“If nothing changes in your life and everything is kept the same, the natural course of psoriasis is sometimes you’ll feel it’s worse than normal — and other times it’s better than normal,” he explains. “That’s just the way chronic inflammatory disease goes.”
But our natural tendency is to want to figure out why psoriasis might be acting up, or what triggers it. “People always want to attribute a flare to something going on in their lives,” says Dr. Fernandez. “As doctors, our job is often to think about that — and think about changes that may have occurred. We then try and determine whether those changes have anything to do with their current flare. That’s challenging.”
Psoriasis triggers generally fall into several categories, Dr. Fernandez says. “With psoriasis, the common triggers are the same ones we know of for most chronic inflammatory diseases.” Determining psoriasis triggers can be challenging, though. They vary from person to person, and can change over time.
But there are four main categories that typically cause psoriasis to flare up.
Dr. Fernandez says one of the most common psoriasis triggers is having an infection — especially a streptococcal infection, which can cause strep throat or other problems. “Strep throat is a well-known trigger, especially for a certain subtype of psoriasis called guttate psoriasis,” he explains. Signs of this psoriasis subtype include small, drop-shaped red spots that appear on your skin.
Of course, you can’t control whether you catch a cold, the flu or another virus. Dr. Fernandez says doctors can offer better treatment if they know you’ve been sick, though. “If you come in with a psoriasis flare, and we find out you’ve recently had a bad upper chest cold, congestion or a cough, it puts things in perspective for us in terms of how to deal with the flare.”
You typically associate taking medication with treating the symptoms of a disease or making a condition better. However, researchers have discovered that certain medications can make psoriasis worse. “Over time, certain blood pressure medications have been shown to potentially flare psoriasis,” Dr. Fernandez says. That includes beta blockers, for example.
He notes that determining whether medication is the flare’s root cause can be challenging. Studies or trials may draw conflicting conclusions. Plus, medication regimens can be complex to manage. Doctors may not advise you to stop taking something suddenly. For example, lithium is known to cause a psoriasis flare, and that’s not a medication you can quit cold turkey.
“If we think the medicine has anything to do with worsening psoriasis, especially given the fact that whoever prescribed those medicines believes that those were important for you to take, we need to look at your options,” says Dr. Fernandez. “We will also communicate with the doctors who have prescribed these medications.”
Chronic or acute stress is known to cause a variety of medical conditions, like high blood pressure, or make existing conditions worse, like eczema. “We hear this all the time — people will come in and say, ‘I’ve been more stressed than normal. And I feel like my psoriasis is worse,’” Dr. Fernandez says. “And there’s some truth to that.” He notes that in recent years, several scientific studies have discovered a link between stress and chronic inflammatory diseases, such as psoriasis.
Environmental exposure is a broad term used to describe things like smells, allergens and even sunlight. “Depending on where you live, during certain times of the year, there may be something in your environment, even if it’s airborne, that could potentially flare your psoriasis,” explains Dr. Fernandez. For example, you might have a psoriasis flare-up in colder months when you’re not in the sun as much. That’s because you’re more exposed to hot, dry air inside.
Figuring out whether something in the environment is triggering your psoriasis can be difficult, Dr. Fernandez adds. “People might come in and say, ‘We can smell the fumes from the factory by my house every fall. That’s when my psoriasis flares.’ Based on that, we’ll try to see if minimizing exposure makes a difference. That’s usually the best we can do.”
Light therapy (especially UVB phototherapy) can be an effective psoriasis treatment. That’s because this mimics the UVB rays from sunlight, which are shown to help the condition’s symptoms. However, Dr. Fernandez warns to keep any exposure to this light to “moderate amounts, where you make sure to avoid tanning and/or burns,” as that can cause additional skin issues.
Smoking is “well known to be a risk factor for developing psoriasis,” says Dr. Fernandez. But he notes that once you have psoriasis, there’s no scientific evidence that stopping smoking will make the condition go away. “In general, we cannot convincingly tell you that if you stop smoking, your psoriasis will improve … There is no study that has really supported that.”
It’s not out of the realm of possibility, however, that being around cigarette smoke could cause discomfort. “If someone comes to see me and says, ‘My psoriasis does well until I go visit my brother’s family. He and his wife smoke and my psoriasis flares,’ we’re going to take that seriously,” says Dr. Fernandez. “In that case, we’re going to recommend avoiding cigarette smoke and see what happens.”
If you know your psoriasis triggers, avoiding them is a good first step. But this isn’t always possible — after all, you can’t always avoid getting sick. And not every psoriasis flare has a clear-cut source, so prevention is complicated. But there are tried-and-true treatments and approaches that doctors have found to be successful.
If your psoriasis treatment is working and you’re doing well, but you suddenly have a flare, Dr. Fernandez says monitoring the situation is a good next step.
“What we don’t want to do is panic and change the old treatment regimen because you’re flaring,” he explains. “Especially if you’ve generally done well on a given regimen. With all the great medicines that we have today, we can usually control psoriasis so that a patient has no more than about 1% body surface area of psoriasis on the skin.” That’s about the size of one palm of your hand. “But when you’re flaring, you’ll have more of that.”
Another good next step is sharing any recent health changes (or challenges) with your doctor. Maybe you recently had an upper respiratory infection — there’s a good chance this infection is what’s causing your immune system to “go a little haywire for a while and contribute to psoriasis flares,” Dr. Fernandez says.
He adds, “Then we’ll keep your maintenance regimen the same and figure out, ‘Well, how are we going to control this flare? How do we get you through these few weeks of having more disease activity than you normally do without changing a treatment regimen that has generally worked well?’” Once your flare subsides, you’ll resume your regular maintenance treatment approach.
After a viral infection has come and gone, your psoriasis flare might be severe enough to require extra TLC (tender loving care!).
“Depending on the severity of the flare, we’re going to add some temporary medicines to calm down active inflammation and psoriasis on the skin,” Dr. Fernandez says. He notes that’s “almost always” going to include topical medications, like a topical steroid — basically a cream or medication applied directly to the surface of your skin.
In some cases, you might need to take something stronger that acts quicker. “We’re going to add medicines that we believe are going to kick in and take control of active inflammation fast,” says Dr. Fernandez. That can be an oral steroid (medicine taken by mouth) or a long-used psoriasis treatment called Cyclosporine.
“Usually, our goal is just to give that to you for a few weeks, and then try to taper you off and see if that flare has run its course,” he says. “Then you can be back to a baseline regimen to control your disease.”
Moisturizer on its own isn’t necessarily a psoriasis treatment. But they can soothe and address side effects of the condition. “If you have psoriasis, any moisturizer usually helps your skin feel better,” advises Dr. Fernandez. “You tend to get psoriasis over joints like the elbow, so bending it stretches the skin. If the skin is really dry, it can crack and bleed and hurt. So moisturizer will help with unpleasant symptoms.”
Moisturizer with salicylic acid is an even better choice to address psoriasis — specifically, the thick scales associated with psoriasis skin lesions. “A moisturizer with salicylic acid can be an effective way to not only make your skin feel better, but also help topical medications work better to control those lesions,” says Dr. Fernandez.“If you have thick scales, topical medications have to penetrate through those and your top layer of skin before reaching the inflammatory cells causing the lesions. Getting rid of these scales — and salicylic acid helps dissolve them — helps topical medicines penetrate and work better.”
Dr. Fernandez says rubbing alcohol is a major product people with a psoriasis flare should avoid.“People might say their psoriasis itches, so they’ll rub alcohol on their skin. Even though alcohol may temporarily relieve itching, the end result is it’s going to cause more irritation and promote more inflammation.”
Researchers are increasingly finding that maintaining a healthy lifestyle is beneficial for people with chronic inflammatory diseases, including psoriasis.
“Eating well, exercising and getting good sleep are all keys to minimizing the chances of a flare and keeping your psoriasis as calm as possible,” Dr. Fernandez says. “Not getting adequate sleep is a stressor on your immune system. Exercise is also good for your immune system. Plus, it also helps promote weight loss — and keeping your weight within a normal range helps with psoriasis.”
Dr. Fernandez adds that taking medication goes hand-in-hand with any healthy lifestyle changes. “Most people with psoriasis need medicine,” he says. “And the reality is, we have outstanding medications whose benefits far outweigh the risks associated with taking them. We believe psoriasis shouldn’t affect anyone’s quality of life with the current treatment options we have — and we can get most people to the point where they are living their life as if they don’t have psoriasis.”