The triggers of psoriasis and how to treat it

Distressing and aggravating for those that have it, psoriasis is an auto-immune condition that affects around two in 100 people in the UK. I am one of them.

In the mid 1980s, at 23 and having just returned with a healthy tan from a summer working on a campsite in the south of France, my brown face was now peppered with pale pink spots, especially round the hairline. Apart from being unsightly, they were itchy.

And, as I subsequently found out from a dermatologist, they were my first signs of psoriasis – a condition I’ve intermittently suffered from ever since. 

What exactly is psoriasis and how can you tell if you have it?

It occurs when certain immune cells are triggered and become overactive, acting as if healing a wound, leading to the rapid growth of skin cells that cause the plaques to form. While you can never get rid of it, knowing your triggers can help you avoid a flare-up, or ‘flare’.

But first of all, it helps to know for sure that it’s definitely psoriasis. “Unlike eczema, which is ill-defined, psoriasis has clear demarcations – there’s a distinct cut-off between normal skin and affected skin,” says Dr Zainab Laftah, a consultant dermatologist with the British Skin Foundation.

The condition can start at any age, but most often develops in adults either between 20 and 30 years old, or between 50 and 60. 

What are the triggers of psoriasis?

Common triggers include stress – in my case, simultaneously struggling to find a job and a flat (and get over a relationship break-up) was the perfect storm. For me it’s manageable, but for some, the condition can hugely affect their quality of life. “People with extreme psoriasis can become socially withdrawn. The impact on their self-esteem can affect daily activities, such as sport and swimming. Psoriasis is associated with metabolic syndrome, so exercise is important in reducing their risk of cardiovascular disease. So, treatment should be sought,” says Dr Laftah. 

“But there’s every reason to be optimistic. Driven by a greater understanding of the molecular drivers of the disease, we now have some incredibly good treatments,” says Professor Catherine Smith, consultant dermatologist and spokesman for the Psoriasis Association.

What are the different types of psoriasis? 

Plaque psoriasis

The most common type, about 80-90 per cent of people living with the condition experience plaque psoriasis, named after the clearly demarcated red plaques formed by a build-up of skin cells that can occur anywhere on the body. These can be red, itchy and sore, with white or silvery scales. In dark skin, the plaques’ appearance may be purple, greyish or darker brown. Common triggers are alcohol, insect bites, skin injury and sunburn.

Guttate psoriasis

Also known as ‘tear drop’ or ‘rain drop’ psoriasis, this is a rash of small spots on the torso, back, limbs and sometimes head, neck and scalp. It tends to occur most often in children, adolescents and younger adults. It’s often triggered after a streptococcal throat infection, or other viral or bacterial infection – and in 2023 researchers found it can be triggered by Covid 19. 

Facial psoriasis

Up to half of people with psoriasis get it on their face. This comes in the form of thick, angry, scaly skin on the forehead, around the eyes, on cheeks or chin, as well as eyebrows, round the mouth and on the sides of the nose. As with other types of psoriasis, genetic predisposition is the root cause, but facial psoriasis can be triggered by an infection, a reaction to a medication, a skin injury or emotional stress. 

Nail psoriasis

Nail psoriasis is discolouration, pitting or separation of the nail from the nail bed, and around 50 per cent of people who have psoriasis get it on their nails. Difficult to treat, it can be very painful and may impact daily activities. “It can affect both hands and feet and can be debilitating and hard to camouflage. There are some biologics (injectable treatments) that have proven effective against nail psoriasis,” says Dr Laftah.

Scalp psoriasis

Causing dandruff-like flakes, it’s common for plaque psoriasis to appear on the scalp, often visible around the hairline as well as on the forehead, neck and behind the ears. It can lead to temporary thinning of the hair, but once managed with the right treatment for your psoriasis, this will grow back.

What is psoriatic arthritis?

Affecting about 30 per cent of people with psoriasis, this is a chronic inflammatory disease of the joints that often appears between the ages of 30 and 50, although children can be affected. Symptoms include swollen, stiff and painful joints and tendons, reduced range of motion, eye inflammation and fatigue. In its most severe form, this can cause permanent disability, so a consultation with a rheumatologist is required to find the right treatment plan. “We know it’s under-diagnosed. If people with psoriasis have joint problems, it’s vital to report them to your doctor,” says Prof Smith.  

What are the lifestyle triggers for psoriasis?

Obesity, alcohol, smoking and an inactive lifestyle can all worsen psoriasis, as can medications like lithium and Beta-blockers. And stress is a major factor. “Major life events and stressful incidents can trigger psoriasis in some people. And there can be a lot of judgement around that – people saying: ‘You’re just stressed, you need to relax,’ when really it’s not as simple as that,” says Prof Smith. 

“We also know that among people with psoriasis, there is prevalent alcohol dependence and misuse, and it’s a bit of chicken and egg thing, because severe psoriasis has a huge impact on people’s lives,” so their alcohol misuse may well be driven by distress over their psoriasis. “We know there’s prevalent depression and suicidality in people with psoriasis. It’s stigmatising and for some people, difficult to live with,” says Prof Smith.

 “If you are overweight or obese, you are more likely to have more severe psoriasis, covering in some cases much of the body. But if you lose weight this may help,” says Prof Smith.

Food and diet triggers

Foods that exacerbate psoriasis include saturated fatty acids like butter and palm oil, red meat and sugar. “Avoid excess alcohol and processed foods and eat lots of fruit and vegetables,” says Prof Smith. Anti-inflammatory foods like leafy green vegetables are believed to help with managing psoriasis.

Environmental triggers

Cold weather can trigger psoriasis flares due to lack of sunlight and humidity and the impact of indoor heating and dry air. A dermatology study found that exposure to air pollution can also cause flares. And while UVB sun rays can ease psoriasis in some cases, bad sunburn can set it off. “Research is ongoing to understand how our genes interact with the environment and to identify the other triggers,” says Prof Smith.

Is psoriasis genetic?

While some people will have a family history of the condition, others may not. But having a family member with the disease increases your risk of getting it. According to the National Psoriasis Foundation, if one of your parents has psoriasis, you have about a 10 per cent chance of getting it, while if both do, your risk is 50 per cent.

“There is often a crossover with other immune-mediated conditions like IBD (Crohns Disease) and certain types of arthritis,” says Dr Laftah. This means these conditions run in families and there’s a cross-link between them. “If for example, one of your parents has IBD and the other has psoriasis, it increases your chance of developing an immune-mediated condition”.

Prof Smith says there are certain factors that drive the risk of patients’ psoriasis being more severe, one of which is their genetic burden. “In other words, if you’ve got a positive family history, that’s one indicator of your likely genetic burden, and if you’ve inherited a lot of the areas in the genome that increase your susceptibility to psoriasis, you are more likely to have it severely”.

What causes late on-set psoriasis?

A peak period for developing late-onset psoriasis is between 50 and 60. “I’ve seen multiple patients get psoriasis for the first time at this age. And in these cases, the first thing we have to rule out is a new trigger. We know that certain drugs, particularly Beta-Blockers for arrhythmia, can cause psoriasis to present,” says Dr Laftah. 

Psoriasis causes in children

Although relatively rare in the very young, it is estimated that a third of people develop the condition before the age of 16. Children will sometimes get psoriasis in response to a throat infection, and it may completely clear up within months and never return, or it could later present as plaque psoriasis. It can affect children of any age – even babies. 

What treatments are available for psoriasis?

While there’s no cure for psoriasis, treatments have come on in leaps and bounds, making it far easier to manage and control. “For people with more extensive disease there’s been a complete step change, with the development of immunomodulatory therapies and biologics. These drugs are designed to target the pathways that are dysregulated or overactive in psoriasis,” says Prof Smith.

Psoriasis creams and phototherapy           

Treatment tends to start with topical therapy  – steroid creams or ointments which for mild to moderate psoriasis can be enough, slowing the production of skin cells and reducing itching. “Alongside steroids, we also prescribe vitamin D analogue cream, which reduces the inflammatory process. If that doesn’t work, we offer photo therapy,” says Dr Laftah. Phototherapy involves exposing the skin to ultraviolet light on a regular basis. Treatments can be done in a health care provider’s office, a clinic, or at home with a phototherapy unit. The  key to success with light therapy is consistency.

Psoriasis home treatments

As a depleted gut microbiome may help trigger psoriasis, studies have shown that taking probiotics can help in improving skin health and reducing symptoms. Taking a supplement called Propolis, a resin-like material made by bees that is derived from tree buds and plants, has been proven to improve symptoms, as has using aloe vera gel. Curcumin, the active ingredient in turmeric, taken in pill form, is another home remedy for alleviating psoriasis. 

In all cases, keeping the skin moisturised is vital, as this will ease itching. Stick to fragrance-free products for sensitive skin, like E45 moisturising cream and lotion, and try using coal tar shampoo for the scalp. The sun’s UVB rays can slow the growth of affected skin cells, so exposure to sunlight can be helpful, on the advice of your doctor. Sunburn can worsen the condition so it’s important to expose the skin gradually, for brief periods, and use fragrance-free sunscreen for sensitive skin.

Immune-suppressant treatments

In cases of severe psoriasis, or where other treatments don’t work, you can be prescribed systemic treatments by a dermatologist, taken in pill form. Immune-suppressant drugs reduce psoriasis by dampening down the immune inflammatory mediated response. While these treatments can be very effective, there are potentially serious side effects, so these need to be discussed with your consultant. 

In some cases, this form of treatment can be essential to your future health. “Twenty per cent of patients who have psoriasis will go on to have psoriatic arthritis, and where that’s involved, regardless of how severe the psoriasis is, they need something that’s going to dampen down that immune system, because any inflammatory response in the joints will cause irreversible damage,” says Dr Zainab Laftah.

Psoriasis injection treatments

Biological treatments or ‘biologics’, taken in injectable form, are usually prescribed on the NHS if you have severe psoriasis that has not responded to other treatments, or if you cannot use other treatments for health reasons.

“Biologics enable treatment to be very selective – only blocking the cells that are involved in inflammatory response, so you get a better response and less side effects,” says Dr Laftah.

For facial psoriasis, Botox may potentially be beneficial, says aesthetic surgeon Dr Jonquille Chantrey: “There is clinical data showing that neurotransmitters are involved in the pathology of various skin conditions, including psoriasis, and Botulinum toxin (Botox) impacts these. The initial data showed that botulinum toxin can improve the symptoms of patients with both stable and active psoriasis. It is crucial however to have a detailed consultation with a doctor who can diagnose whether injectable procedures are safely indicated.”

Psoriasis and acupuncture

In my case, the treatment that has helped me the most whenever psoriasis has reappeared in my life – at times of stress, following illness and, in particular, during menopause – is acupuncture combined with Chinese herbs.

Commonly used to tackle psoriasis in China, and with a low risk of side effects, studies are ongoing, but it’s believed acupuncture reduces itching and inflammation by accelerating absorption of metabolites, and may improve the immune function of the body and repair skin lesions. It’s the combination of the herbs and needles that have quicker results, says acupuncturist Lei Zhou An, who is a member of the Register of Chinese Herbal Medicine (RCHM). “The acupuncture helps to calm your stress, regulating your sleep and menstrual cycle, while the herbs change the pathology to improve symptoms”. To find a reputable trained practitioner, go to the RCHM or the British Acupuncture Council. 

For more information go to www.psoriasis-association.org.uk and myskin.org.