Psoriasis: burning down the host

A fire does not require a lot to consume a room. A burning cigarette on the carpet can lead to a small fire, which can rapidly spread and light up the room. The spreading of the fire depends on the type of materials present in the room; some carpets and curtains will catch on more easily and accelerate the fire. In addition to the roaring flames, there is also the dangerous smoke, which upon inhalation can lead to a quicker death than the burning flames.

Surprisingly, psoriasis compares well to such a dramatic incident. The burning cigarette can be regarded as a trigger, for example, the Koebner phenomenon, which can lead to psoriatic lesions (1). Depending on the genetic susceptibility (carpet) of the host and its environment (curtains), this may lead to a chronic skin condition (spreading flames) with associated comorbidities (smoke). The intimate interplay between the genetic background and the environment is mediated by well-known protagonists called cytokines. In this metaphor, cytokines can be regarded as the sparks that spread the fire. The associated comorbidities, here represented by smoke, may be more potentially dangerous than the cutaneous affliction itself. Psoriasis patients have an increased risk to develop metabolic syndrome, diabetes, cardiovascular diseases and immune-mediated inflammatory diseases (IMIDs) (2–4). These heightened risks lead to reduced life expectancy in psoriasis patients (5), who are thus rather intoxicated by the smoke than consumed by the flames.

As with all fires, it is crucial to act early and efficiently. In the case discussed here, it would be wise to take the burning cigarette, extinguish it and make sure the carpet is not catching on. Translated, anything that might lead to a Koebner phenomenon in a susceptible person, such as wounds and infections, should be treated prophylactically/prematurely to avoid the development of a lesion. In addition, it does not suffice to extinguish the sparks when the curtains are already on fire. The curtains represent the environment that might act as a catalyst for psoriasis development, so in addition to treatment with biologics such as anti-TNF and anti-p40 drugs, one should identify potential triggers in the environment such as an unhealthy diet, lack of exercise, alcohol consumption and ironically, smoking. By changing the type of curtains through a healthier life style, one may actually delay the spreading of the fire and thus the development of smoke, here the associated comorbidities.

But nevertheless, quenching of the sparks is crucial as well. But in contrast to today’s perception, a simple treatment with topical corticosteroids or biologics might not suffice to extinguish the psoriatic burning. Rather, a combined treatment of topical steroids with methotrexate or with biologics will result in a better control of the psoriatic flames.

Ideally, the flames are controlled early to reduce damage with the least aggressive means. In psoriasis, this means the patient should see a physician as soon as possible to minimize the spreading of lesions. Perhaps, there may be a window of opportunity in psoriasis, similar to psoriatic and rheumatoid arthritis. It has been postulated to treat psoriasis early and “targeted”, with the outcome of complete clearance of lesions, or no smouldering ashes left (6). In this respect, it is compelling to educate the patient as well and provide insight in his/her condition to treat the lesions early and consistently. By treating psoriasis as a burning room, with various components acting as accelerators, we may be able to tackle this disfiguring disease prematurely and effectively.