Still a Heartbreak: Psoriasis, Rosacea, and Eczema

Once a popular advertising clich?, "the heartbreak of psoriasis" is a catchphrase that still resonates with many image-conscious victims of psoriasis, rosacea, and eczema. As well as being physically annoying, these chronic conditions may embarrass or depress their sufferers, some of whom avoid social contact altogether.

Psoriasis

Normal skin keratinocytes mature in 21 to 28 days, but psoriatic cells mature within 2 to 3 days, accumulating as dead layers on the skin's surface (parakeratosis). Sharply demarcated chronic erythematous plaques (red patches), generally covered with silvery white scales, erupt.¹ Elbows, knees, scalp, umbilicus, lumbar regions, fingernails, toenails, and areas with skinfolds are most likely to become itchy and uncomfortable. Symptoms may be mild (<3% of the body affected), moderate (3% to 10%), or severe (>10%). Numerous subtypes exist. Psoriatic arthritis?the most severe form?comprises about 10% of cases.¹

Etiology

The etiology of psoriasis appears to be multifactorial, but evidence suggests T-lymphocyte-based immunopathogenesis.² Although a genetic basis exists, environmental triggers exacerbate symptoms. Injury, infections (especially streptococcal upper respiratory infections), medications (eg, beta-blockers), alcohol, and physical and emotional stress all have been implicated.^1,3 Symptoms generally improve in the summer and worsen in the winter.

Although ~2% of the population has psoriasis, blacks are at significantly lower risk.³ The condition generally surfaces between ages 15 and 35, affecting both genders equally.⁴

Treatment

Pruritus control should be the focus of treatment. Cooling and moisturizing the skin and avoiding irritating fabrics are fundamental, especially in the winter when the air is drier. Ice packs may help, as may heavy moisturizing creams applied often.

Prescription treatments include topical treatment with anthralin, vitamin D³, salicylic acid, corticosteroids (see Box), tar, or tazarotene; applications of coal tar ointment with phototherapy, using the less carcinogenic ultraviolet B light, over a 3-week period; and systemic treatment with acitretin, cyclosporine, methotrexate,³ or biologics such as infliximab,^5,6 etanercept,⁷ and adalimumab.⁸ Often, dietary changes and exposure to sunlight or natural thermal springs, hot springs, mineral water, or seawater can improve the condition.³

Eczema

The umbrella term eczema encompasses several inflammatory skin conditions. The most common form is atopic eczema (AE), also called atopic dermatitis. This chronic pruritic disease generally starts in infancy.⁹ AE most often presents as dry, red, extremely itchy patches on the forehead, cheeks, forearms, legs, scalp, and neck and on the inside of the elbows, knees, and ankles.¹⁰ Compulsive scratching creates redness and rash, and ultimately lichenification (thick leather-like skin texture). Small bubbles (vesicles), visible with the naked eye, appear as spongiosis (intracellular edema) microscopically.¹¹ At times, eczema may "bubble up" and ooze.¹⁰ (Eczema comes from the Greek word ekzein, meaning to "boil out.")

Eczema is genetically passed in some cases, but, as with psoriasis and rosacea, patient-specific triggers play a role. The more common include skin contact with coarse materials (eg, wool), soaps, lotions, liquid or sheet fabric softeners; contact with fresh fruit juice or meat, dust mites, or animal saliva; respiratory infections; food sensitivity; and frequent bathing.¹⁰

Predominantly a childhood condition, eczema occurs in 10% to 20% of all infants; 60% of these will have symptoms within their first year, and up to 85% by age 5.¹¹ Earlier onset is associated with greater severity. Up to 50% of children improve significantly between ages 5 and 15. Another form, nummular eczema, is seen primarily in adult males between 55 and 65 years old.¹⁰

Etiology and pathogenesis are not fully understood, but immunologic deregulation?particularly an increased Th2 immune response?appears to be present.^9,11

Treatment

Again, the primary goal is relief of discomfort. Because eczema usually is dry and itchy, most treatment plans involve applying emollients. Lifestyle modifications must be tailored to individual patients. Topical antipruritics and nonsedating antihistamines can help. If itching is severe, sedative antihistamines may be necessary. Should Staphylococcus aureus or streptococcal infection be present, topical or systemic antibiotics are used. Some severe eczema responds to phototherapy. Corticosteroids and cyclosporine may be prescribed for eczema that is unresponsive to other interventions.^10,11

Rosacea

Rosacea has several chronic symptom constellations. Unlike eczema or psoriasis, it is a facial problem. Its 4 subtypes (erythematotelangiectatic, papulopustular, phymatous, and ocular) have intermittent or continuous facial flushing; central facial inflammatory papules and pustules; permanent vessel dilation (telangiectasia); disfiguring sebaceous gland hypertrophy on the nose with fibrosis (rhinophyma or bulbous nasal swelling); photosensitivity; and ocular dryness, conjunctivitis, and blepharitis in various degrees.^12,13

Up to 10% of the population may be affected (14% of females, 5% of males). Rosacea is easily confused with other conditions, and mild cases often are unreported. Fair-skinned people, especially those of Northern European or Celtic descent, and perimenopausal women present with greater frequency. Onset generally occurs between ages 30 and 50, but older men are more likely to have advanced disease or rhinophyma.¹³

Genetic and environmental factors seem to be causes, but pathogenesis is vascular and inflammatory. Disease progression varies considerably; remission and relapse are common. Untreated, rosacea can progress to irreversible disfigurement. Sun exposure, heat, alcohol, hot beverages, stress, spicy foods, certain medications (eg, vasodilators), menstruation, cosmetics, and lotions can cause flares.¹⁴

Treatment

Again, avoiding triggers is imperative but often very difficult for rosacea sufferers. Steroids are ineffective; they should be avoided. Topical anti-inflammatories, such as metronidazole¹⁵ and azelaic acid,¹⁶ help in mild-to-moderate cases. Tetracycline, minocycline, erythromycin, and doxycycline are used systemically, not as antibiotics, but as anti-inflammatories. Although papules and pustules typically respond within weeks, redness and flushing are stubbornly persistent. Electrosurgery and laser surgery reduce telangiectasia and rhinophyma, with little scarring or damage. Surgical removal of rhinophyma- related excess tissue usually will improve the patient's appearance.^12,14

Summing It Up

Psoriasis, eczema, and rosacea have much in common. The initial presentation can look like an allergic reaction, so obtaining a good patient history is important. Once these conditions have been diagnosed, patients should bathe or shower no more than once daily with lukewarm water and very mild soap (Cetaphil, Oil of Olay, Basis, or Dove), because hot water and soaps have a drying effect. Patients should pat affected areas dry without rubbing, leaving some moisture on the skin. They can apply unscented oils or emollients after showering or bathing. Keeping a diary of what helps and what does not can identify triggers to be avoided. One difference among these conditions is that patients with rosacea should wear sunscreen daily and avoid sunlight.

All of these conditions wax and wane, and patients must be prepared to try medications for adequate durations. Stubborn symptoms can take weeks to months to resolve. Patients must implement a program that employs many interventions for the remainder of their lives.

Dr. Zanni is a psychologist and health-systems consultant based in Alexandria, Va. Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Md. Views expressed in this article are those of the authors and not those of any government agency.

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