Psoriasis

M. Alan Menter, Caitriona Ryan, M. Alan Menter, Caitriona Ryan

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781351645607
• Edition: 2
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The new edition of a concise yet thorough illustrated review of the diagnosis and treatment of many forms of psoriasis now includes the many new therapies available and in development, as well as more material on psoriasis as a systemic disease and on comorbidities. This will be of interest to all dermatologists in training and practice, as well as primary care physicians.

1

The history of psoriasis

M. ALAN MENTER and BOBBAK MANSOURI

BIBLICAL TIMES

Psoriasis is one of the many dermatological conditions, including leprosy, which has been described since Biblical times. In the Hebrew bible, the term “tzaraath,” translated as leprosy, was used as a term of punishment or “ritual uncleanliness.” In the case of Gehazi (2 Kings 5:27), there is a specific biblical reference to psoriasis, “But Naaman’s leprosy will cling to you and your descendants forever. And Gehazi left his presence a leper, white as snow.”¹ In addition, ancient Egyptian and neighboring lands’ scrolls frequently mention the term “leprosy”—again, mistaken in many instances for psoriasis. In 550 B.C., Greek athletes used special showers and application of olive oil to heal and protect their skin, whereas ancient poets Aeschylus and Herodotus described “leprosy,” “leuke,” and “psora” as diseases of the skin. Finally, Hippocrates (460–377 B.C.) freed medicine from the realm of superstition and magic with his meticulous descriptions of many disorders, including conditions of the skin. Dry, scaly eruptions were grouped together under the term “lopoi” (meaning epidermis), which likely included both leprosy and psoriasis.¹

FIRST CENTURY A.D.

Cornelius Celsus, the Roman author (25 B.C.–45 A.D.), described psoriasis as the fourth variant of “impetigo” in his work De re medica.² Thereafter, the Roman physician Galen (133–200 A.D.) first used the term “psoriasis vulgaris” derived from the Greek word “psora” (meaning itch) to describe an affliction of the skin for which he administered arsenic in many different forms as a “cure.”³ However, the confusion between leprosy and psoriasis endured for many centuries with psoriasis patients between the years 1000 and 1400 A.D. receiving brutal treatment, being isolated from both their communities and their church, and even being burned at the stake by Philip the Fair of France in the fourteenth century.⁴

THE RENAISSANCE PERIOD

The “Renaissance” was a time of revival. Classical learning and wisdom brought to the fore the emergence of a more scientific understanding of psoriasis. Medicine experienced a rebirth with the cities of Vienna, Paris, and London becoming the center of the newly found specialty—dermatology. In Vienna, Joseph Jacob Plenck wrote of psoriasis in 1776 as being among the group of desquamative (scaly or scale-like) diseases but did not differentiate it from other dermatoses. Subsequently, in the late eighteenth century, two Yorkshire-born English dermatologists, Robert Willan (1757–1812) and Thomas Bateman (1778–1821), differentiated psoriasis from other skin diseases. Willan is considered to have first described psoriasis and identified two varieties of the disease. “Leprosa Graecorum” was used to describe the condition when scaling of the skin was predominant, whereas the second term, “Psora Leprosa,” described a more eruptive variant of the condition.⁵ Willan wrote the first textbook entitled Cutaneous Disease (published in 1798), which contained color photographs of psoriasis and established him as the father of modern dermatology. Bateman, on the other hand, was the first to consider a link between psoriasis and arthritic symptoms.

Despite these important writings, psoriasis continued to be confused with leprosy until 1841 when the Viennese dermatologist, Ferdinand von Hebra, gave the condition its definitive name “psoriasis,” derived from the Greek word “psora” meaning “to itch,” and eliminated “lepra.”⁶ Von Hebra improved on Willan’s original system of classification by relating clinical disease to pathologic anatomy.

In 1872, Heinrich Koener (1834–1904) described the induction of lesions of psoriasis within areas of prior trauma in an address delivered to the Silesian Society for National Culture. This has since become known as the “Koebner” phenomenon.⁷ Subsequently, Heinrich Auspitz (1835–1886) described both the characteristic histological features of psoriasis and the eponymous clinical sign of pinpoint bleeding on the removal of psoriatic scale.⁸ Finally, in the descriptive era on the origins of psoriasis as a separate disease, Leo Ritter von Zumbusch (1874–1940), a Viennese physician, was the first to document generalized pustular psoriasis in the early 1900s after observing a single male patient through nine hospital admissions over a 10-year period.⁹

EVOLUTION OF MODERN THERAPIES

Arsenic: For centuries arsenic was used to treat psoriasis and other skin diseases with historical records showing its use as far back as Hippocrates. Thomas Fowler developed a treatment that was a solution of potassium arsenite compounded with a tincture of lavender for color and taste. Known as “Fowler’s Solution,” it was “peer reviewed” by Thomas Girdlestone in a paper entitled “Observations on the effects of Dr. Fowler’s Mineral Solution in Lepra and Other Diseases.” Arsenic was actually still used in the treatment of psoriasis as recently as the 1950s.

Tars: Tars were also used by Hippocrates. In the late 1800s, tar was used topically in conjunction with arsenic. Coal tar became available with coal gas production in the second half of the nineteenth century and still maintains a role in the treatment of psoriasis. The slogan “The Heartbreak of Psoriasis” originated in the advertising campaign for Tegrin®, which was a coal-tar based ointment. In 1921, Goeckerman initiated the use of coal tar in a hospital-based regimen with phototherapy, 24 hours a day at the Mayo Clinic.

Goa Powder or Chrysarobin: Goa Powder was a Chinese remedy, derived originally from the pith of a tree from Goa, a Portugese enclave off India. Goa Powder was mixed with water, lime juice, or vinegar to make a paste that was spread onto the skin. It was often also mixed with cold lard.

During World War I, when Goa Powder was difficult to obtain, Bayer synthesized a substitute called dithranol in Europe or anthralin in the United States. After the application of anthralin, patients were wrapped in a dressing for 24 hours, a technique pioneered by Ingram in Leeds, England, in 1948. Although effective, anthralin therapy was time consuming and often caused irritation and/or staining of the skin. These difficulties ultimately led to modifications of the regimen, and by the 1970s, the 24-hour period had been reduced to 6–9 hours a day, similar to the newly developed day care schedule of the Goeckerman regimen. Thereafter, at Stanford, shorter contact anthralian therapy (SCAT), i.e., 1–2 hours application time, was introduced by Eugene Farber in the early 1980s.

Folic Acid Antagonists: The folic acid antagonists, aminopterin and amethopterin, were used in dosages from 1.5 to 2 mg daily with improvement in the condition generally observed after 2 weeks. Initial studies were commenced in California in the 1950s under the supervision of Rees B. Rees.¹⁰ Toxicity was, however, a constant problem, with aminopterin still being used as late as the 1960s, before being definitively replaced by its metabolite, methotrexate,¹¹ the first oral drug approved by the U.S. Food and Drug Administration (FDA) for the treatment of severe psoriasis in 1971.

Phototherapy and Photochemotherapy: Broadband ultraviolet B (UVB) was initially used in the treatment of psoriasis in the early 1900s, before being replaced by narrowband (NB UVB) phototherapy, initially in Europe over 40 years ago. After almost a century of various forms of UVB therapy, psoralen-ultraviolet light A (PUVA) was finally approved for the treatment of psoriasis in 1976 with the majority of research having been performed by John A. Parrish and his colleagues at Harvard.¹³

Systemic Retinoids: Etretinate was the first systemic retinoid developed for the treatment of psoriasis being approved by the FDA in 1986.¹⁴ Acitretin, a second generation systemic retinoid, replaced etretinate shortly thereafter. Retinoic acid acts by modulating and normalizing the proliferation of the otherwise hyperproliferative epidermis in psoriatic lesions by activating retinoic acid nuclear receptors.¹²

Cyclosporine: Cyclosporine was discovered in the early 1970s and was originally used as an immunosuppressive agent in organ transplantation.¹⁷ An anecdotal report of its efficacy in...