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Dermatologist and Venereologist in Ajman and Dubai

Psoriasis: Different Types

Published by Dr Hanish Babu, MD, Dermatologist & Venereologist, City Medical Centre Ajman and Cosmolaser Medical Centre, Sharjah, UAE.

Classifications of Psoriasis

Psoriasis is classified into various types depending upon the morphology (appearance), clinical types and severity and extent of the disease.

Types of Psoriasis
Types of Psoriasis

1. Morphological Classification of Psoriasis

This classification depends upon the appearance of skin lesions:

  • Guttate Psoriasis: Rain drop like lesion, sudden onset, seen usually in children.
  • Plaque Psoriasis (Psoriasis vulgaris): The common raised patch (plaque) variety
  • Inverse Psoriasis (Flexural Psoriasis): Involves the body folds like axilla, groin, below the breasts and in between the buttocks.

2. Life Style: Quality of Life

Psoriasis can also be classified depending upon how patient’s life style or quality of life is affected by the disease.

Mild Psoriasis
  • Disease does not alter the patient’s quality of life. 
  • Patients can minimise the impact of disease and may not require treatment.
  • Treatments have no known serious risks (e.g., class 5 topical steroids). 
  • Generally less than 5% of body surface area is involved with disease.
Moderate Psoriasis
  • Disease does alter the patient’s quality of life.
  • The patient expects therapy will improve quality of life.
  • Therapies used for moderate disease have minimal risks
  • Generally between 5% and 20% of body surface area is involved with disease.
Severe Psoriasis
  • Disease alters the patient’s quality of life.
  • Disease does not have a satisfactory response to treatments that have minimal risks.
  • Patients are willing to accept life-altering side effects to achieve less disease or no disease.
  • Generally more than 20% of body surface area is involved with disease.
Other factors that may affect the Severity Classifications are:
  • Patient’s attitude about disease
  • Location of disease (eg, face, hands, fingernails, feet, genitals)
  • Symptoms (eg, pain, tightness, bleeding, or severe itching)
  • Arthralgias (joint pain) / arthritis (joint inflammation)

3. Clinical Staging

  1. Acute Eruptive Psoriasis: This is the guttate variety which suddenly appears all over the body and spreads fast.
  2. Chronic Progressive Psoriasis:  The common plaque psoriasis, also known as psoriasis vulgaris, with a progressive clinical course.
  3. Chronic Stationary Psoriasis: When the psoriasis lesions remain stationery without increasing in size and with a dull red colour and minimal scaling, this is a stationary stage. This stage usually precedes the regressive stage.
  4. Chronic Regressive Psoriasis: With or without treatment, psoriasis lesions gradually become thin, scaling reduces, the red color changes from dull red to violaceous and gradually fade. In those who have used steroids or ultraviolet radiation, a hypopigmented (whitish) ring known as Woronoff’s ring may be seen surrounding the lesion.

Several other methods exist for measuring the severity of psoriasis. These scales are generally based on the following factors: the proportion of body surface area affected; disease activity (degree of plaque redness, thickness and scaling); response to previous therapies; and the impact of the disease on the person.

The Psoriasis Area Severity Index (PASI) is the most widely used measurement tool for psoriasis. PASI combines the assessment of the severity of lesions and the area affected into a single score in the range 0 (no disease) to 72 (maximal disease).

Read more about Psoriasis:

Disclaimer

The information given in this article is for educational purpose only so that patients are aware of the options available for diagnosis and treatment of common skin, hair and nail diseases. No diagnosis should be made or treatment undertaken without first consulting your dermatologist. If you do so, the author will not be responsible for any consequences. The images provided are for illustration purpose only and should not be reproduced without the consent of the author.

About the Author of Skin Care Tips from Dermatologist: Dr Hanish Babu, MD
Dr Hanish Babu, MD, Dermatologist, Sharjah and Ajman, UAE
Dr Hanish Babu, MD

Dr Hanish Babu, MD is a dermatologist with more than 3 decades of experience in treating skin and sexually transmitted diseases in UAE and India. He has been practicing in UAE since last 22 years. He is a respected speaker during the Continuing Medical education Programmes for doctors, medical students and paramedical staff and is also a Stress Management Trainer. He organises group therapy sessions for patients with psoriasis, eczema and vitiligo.

He is available for consultation at Cosmolaser Medical Centre in Samnan, Sharjah (06 5678 200) from 10 am – 2 pm and at City Medical Centre, Al Bustan, Ajman (06-7 441 882) from 4.30 pm – 9.30 pm.

Visit his personal website  dr-hanishbabu.com for more details and for educational articles on Skin, hair, nail and sexually transmitted diseases. Click here to Book an Appointment with dermatologist Dr Hanish Babu, MD

Signs & Symptoms of Psoriasis

By Dr Hanish Babu, MD, Dermatologist & Venereologist, City Medical Centre Ajman and Cosmolaser Medical Centre, Sharjah, UAE.

COMMON PRESENTATIONS OF PSORIASIS

clinical types of psoriasis
Clinical Types of Psoriasis

 Psoriasis signs and symptoms vary according to the morphology, stage and anatomical site of involvement of the psoriasis rashes, which are typically scaly plaques on a red base of skin.

Psoriasis is characterised by the development of erythematous (reddish), well defined, dry, scaly, papules and plaques of sizes ranging from a pin head to palm sized or larger. Lesions have a full rich red (salmon) color in the skin of Caucasians. Rarely, lesions on the legs or trunk may show a violaceous or bluish hue.

Psoriasis usually begins as small, erythematous, scaly papules that gradually enlarge to form well demarcated, raised, erythematous plaque with a scaly surface.

The scales in psoriasis are typically silvery white, dry, brittle and arranged in a lamellated fashion. This silvery white color is due to refraction of light through the air trapped in between the scales. The upper scales fall off in large quantities, while the lower layers of scales are firmly fixed.

Grattage Test

Auspitz sign in Psoriasis

Gentle scrapping of the surface of a psoriasis plaque with a glass slide will remove the loosely attached scales and reveal a shiny surface peppered with fine bleeding points. These bleeding points represent the dilated and tortuous capillary blood vessels in the papillary dermis, one of the characteristic pathological events taking place in psoriasis affected skin. This sign is known as Auspitz sign, which is a diagnostic sign of psoriasis.

The number of lesions in psoriasis may be a few or numerous. When multiple, they are arranged in a symmetrical fashion on the body.

The commonest sites for psoriasis are the extensor surfaces of the elbows and knees, low back (sacrum), and the scalp, but any part of the body may be involved.

Nail and joints may also be involved in psoriasis. Progressive painful joint swelling is seen in 10-30% of psoriasis patients.

Another characteristic of psoriasis is the Koebner phenomenon, whereby, new psoriasis lesions appear on areas of skin injury. The injury should reach the level of dermis for the Koebner phenomenon to appear. Superficial scratches involving the epidermis alone will not produce new psoriatic rashes.

Psoriasis derived its name from Sora (Gr), meaning itching. Itching is a prominent symptom in most cases, but varies greatly in intensity from case to case. Some patients do not experience itching at all. In the eruptive stage, when new lesions appear and the present ones progressively enlarge, a warm, burning sensation may be felt by the patient.

Clinical Types of Psoriasis

Depending upon distinct morphological and anatomical characteristics, psoriasis may be divided into different clinical types.

Depending upon the sites of involvement, psoriasis may be classified as scalp psoriasis, trunk psoriasis, flexural psoriasis, palmo-plantar psoriasis, psoriasis glans and nail psoriasis.

Common morphological clinical types of psoriasis are: guttate psoriasis, common plaque psoriasis, inverse or flexural psoriasis, pustular psoriasis and erythrodermic psoriasis.

Guttate Psoriasis

guttate psoriasis
Guttate Psoriasis

Guttate Psoriasis is a special variant which primarily occurs in children and young people following a streptococcal throat infection. Drop-like, scaly patches appear on the entire body. In many cases, the condition disappears by itself after a few weeks or months. This type of psoriasis responds very well to systemic antibiotics.

Common Plaque Psoriasis

Psoriasis Vulgaris
Plaque Psoriasis

Plaque psoriasis is the commonest type of psoriasis, also known as psoriasis vulgaris, occurring in about 80% of psoriasis patients. Common plaque psoriasis usually begins as small, erythematous, scaly papules that gradually enlarge to form well demarcated, raised, erythematous plaque with a scaly surface.

 Inverse or Flexural Psoriasis

This type of psoriasis occurs in skin folds (flexures). Red, itchy plaques appear in the armpits, under the breasts, on the stomach, in the groin or on the buttocks. The plaques are often infected by the yeast-like fungus candida albicans. Scales are usually absent in inverse psoriasis.

Psoriasis Nails

Psoriasis of the nail often manifests itself as small indentures in the nails. These are known as nail pits. Nail pits , though, is not a feature of psoriasis alone, many other skin conditions like alopecia areata can be associated with nail pits.

Psoriasis Nail with Pits

When the nail involvement is severe, the  nail thickens and crumbles away. Nail involvement is most common when psoriatic joint (psoriatic arthritis) involvement is present.

Psoriasis of the Scalp

Scalp Psoriasis

Psoriasis of the scalp can be difficult to distinguish from a severe case of dandruff or seborrheic dermatitis, and sometimes the two occur simultaneously. Thick scaly plaques localised to certain areas are typical of psoriasis scalp.

Pustular Psoriasis

Pustular Psoriasis

Pustular psoriasis is a rare variant where the inflammation is so severe that, in addition to the usual lesions, blisters or pustules containing fluid appear on the skin. This can be localised to the palms and soles or generalised, spreading all over the body

Erythrodermic Psoriasis

Erythrodermic Psoriasis

Erythrodermic psoriasis is the most severe form of psoriasis, which resembles a bad case of severe sunburn with redness, scaling and swelling of the skin all over the body.

Psoriatic Arthritis

Psoriatic Arthritis

In around  10 to 30% psoriasis patients, a debilitating joint disease, known as Psoriatic Arthritis may develop. It causes inflammation in and around the joints and affects an estimated 28 million psoriasis patients. People with psoriatic arthritis experience progressive joint pain and swelling, which is often coupled with scaly, red skin lesions on other areas of the body.

Clinical Types of Psoriasis According to Activity

Acute eruptive: This is the guttate variety which suddenly appears all over the body

Chronic progressive: The common plaque psoriasis, also known as psoriasis vulgaris. This gradually progress in size and number.

Chronic stationary :When the psoriasis lesions remain stationary without increasing in size and with a dull red colour and minimal scaling, this is a stationary stage. This stage usually precedes the regressive stage.

Chronic regressive: With or (sometimes)without treatment, psoriasis lesions gradually become thin, scaling reduces, the red color changes from dull red to violaceous and gradually fade. In those who have used steroids or ultraviolet radiation, a hypopigmented (whitish) ring known as Woronoff’s ring may be seen surrounding the lesion.

Choice of treatment differs  for each of these types of psoriasis.

Read more about Psoriasis:

Disclaimer

The information given in this article is for educational purpose only so that patients are aware of the options available for diagnosis and treatment of common skin, hair and nail diseases. No diagnosis should be made or treatment undertaken without first consulting your dermatologist. If you do so, the author will not be responsible for any consequences. The images provided are for illustration purpose only and should not be reproduced without the consent of the author.

About the Author of Skin Care Tips from Dermatologist: Dr Hanish Babu, MD
Dr Hanish Babu, MD, Dermatologist, Sharjah and Ajman, UAE
Dr Hanish Babu, MD

Dr Hanish Babu, MD is a dermatologist with more than 3 decades of experience in treating skin and sexually transmitted diseases in UAE and India. He has been practicing in UAE since last 22 years. He is a respected speaker during the Continuing Medical education Programmes for doctors, medical students and paramedical staff and is also a Stress Management Trainer. He organises group therapy sessions for patients with psoriasis, eczema and vitiligo.

He is available for consultation at Cosmolaser Medical Centre in Samnan, Sharjah (06 5678 200) from 10 am – 2 pm and at City Medical Centre, Al Bustan, Ajman (06-7 441 882) from 4.30 pm – 9.30 pm.

Visit his personal website  dr-hanishbabu.com for more details and for educational articles on Skin, hair, nail and sexually transmitted diseases. Click here to Book an Appointment with dermatologist Dr Hanish Babu, MD

Psoriasis Triggers

Written by Dr Hanish Babu, MD, Dermatologist & Venereologist, City Medical Centre Ajman and Cosmolaser Medical Centre, Sharjah, UAE.

We have already seen the basic causes of psoriasis. Certain factors in the day to day life of individuals with a genetic predisposition may trigger an attack of psoriatic rashes in the body.

Causes and Triggers of Psoriasis
Causes and Triggers of Psoriasis

The triggering event in psoriasis may be unknown in most cases but is likely an immunologic event caused by any of the allergens described below.

Pathogenesis of Psoriasis
Pathogenesis of psoriasis  (Image Ref: Mahajan R,Handa S.Pathophysiology of psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:1-9)

Commonly, the first lesion appears after an upper respiratory infection, such as streptococcal pharyngitis, especially in guttate psoriasis.

Perceived stress can cause exacerbation of psoriasis. Some authors suggest that psoriasis is a stress-related disease and offer findings of increased concentrations of neurotransmitters in psoriatic plaques.

Guttate psoriasis has been recognised to appear following certain immunologically active events, such as streptococcal pharyngitis, cessation of steroid therapy, and use of antimalarial drugs.

Also of significance is that 2.5% of those with HIV develop psoriasis during the course of the disease, implicating immune factors in the causation of psoriasis.

Stress as a Trigger of Psoriasis

Psoriasis is more stress sensitive than many other skin diseases. Many stressful events of daily life may exacerbate psoriasis. The disease itself may cause a ‘reactive depression’ in the patient which could further exacerbate his psoriasis. A vicious cycle is thus set up.

The Stress Psoriasis Cycle

A number of studies have shown that psychological stress is often caused by psoriasis, and can be a factor in psoriasis flare ups.

Conversely, psychological stress can affect the course of the disease as well as contribute to psychological problems such as depression, anxiety, and unfocused anger. The way stress affects the patient varies from individual to individual; the most common manifestations are psychological depression, anxiety, and obsessional behaviours.

The way in which stress, depression and anxiety influence the course of psoriasis is not known. Some studies suggest that the influence may be through an effect on the immune system. Stress has far reaching effects not only on the immune system, but the neuro-endocrinological systems as well.

Local Skin Injury as a Trigger of Psoriasis

Koebner phenomenon, also known as isomorphic response, refers to the induction of lesions following local trauma or injury to the skin.

Koebner Phenomenon in Psoriasis
Psoriasis: Koebner or Isomorphic Phenomenon

Superficial trauma to the epidermis alone will not induce the new lesions, injury to the upper part of dermis (papillary dermis) is necessary for the Koebner’s to occur. Insult to the skin may be of any kind, for e.g.physical (cuts), chemical(burns), mechanical (rubbing),allergic(contact dermatitis) etc.

There have been many case reports of Koebner phenomenon developing at sites of surgical wounds, sunburn, chickenpox scars, vaccination ulcers and other skin eruptions.

It usually occurs within 7 to 14 days of injury to the dermis, the interval may vary from 3 days to 3 weeks. Koebner phenomenon has also been reported at sites of bites(insects, animals), drug reactions, herpes zoster, skin tests also.

Research shows that about 50% of people with psoriasis experience the Koebner phenomenon

About 10% of psoriasis patients develop a new psoriatic lesion each time the skin is injured. The likelihood of developing the Koebner phenomenon may increase when psoriasis lesions are already present.

Infections as a Trigger of Psoriasis

Studies show that some infections can trigger psoriasis. It is common for people with a family history of psoriasis get strep throat and develop their first psoriasis lesions two weeks later. Strep throat often precedes an outbreak of guttate psoriasis. Inverse psoriasis is frequently aggravated by a thrush infection.

Some Infections Triggering Psoriasis

Common infections that can trigger psoriasis are:

  • Candida albicans (thrush)
  • Human immunodeficiency virus (HIV)
  • Staphylococcal skin infections (boils)
  • Streptococcal pharyngitis (strep throat)
  • Viral upper respiratory infections.

Treating the infection in many cases lessens or clears the psoriasis.

Medications as a Trigger of Psoriasis

Many drugs are known either to precipitate or to exacerbate psoriasis. Rather than being simple drug reactions, these observations throw some light on the aetio-pathogenesis of psoriasis.

A number of beta-adrenoreceptor blocking drugs – propranolol, practolol, metaprolol and oxyprenolol- used to treat hypertension and heart disease have been reported to induce a papulo-squamous eruption that resemble psoriasis.

The cyclic AMP(cAMP) level in psoriatic epidermis is decreased and this decrease may induce accelerated turn over of epidermal cells. Beta blockers further reduce cAMP levels and thereby exacerbate psoriasis. The lesions produced by these drugs are less scaly and less erythematous. The palms, soles and elbows are only rarely involved, and the eruption usually subsides within 2 to 6 weeks of cessation of beta-blocker therapy.

Non-steroidal anti-inflammatory drugs, indomethacin, salicylates, diclofenamate, phenylbutazone, oxyphenbutazone and ibuprofen have been reported to either precipitate or exacerbate psoriasis.

Treatmentof depression with lithium compounds in psoriasis patients can destabilize and exacerbate the psoriasis.

Precipitation of generalised pustular psoriasis in patients with stable psoriasis vulgaris has also been reported following lithium treatment for manic-depressive psychosis.

Lithium compounds have an inhibitory effect on adenyl cyclase and reduce hormone induced accumulation of cAMP in vitro. This may be the mechanism of exacerbation of psoriasis in these patients.

Trazodone, another new anti depressive drug which is a serotonin antagonist, can also cause generalized pustular psoriasis. This suggests that an alternate mechanism may also be involved.

Too rapid a withdrawal of corticosteroid therapy in patients with psoriasis may result in precipitation of generalised pustular psoriasis or may cause exfoliative erythroderma as a rebound phenomenon. Occasionally, topical corticosteroids, especially the more potent ones, also cause such exacerbations.

Chloroquine is another drug that has been known to exacerbate psoriasis, often leading to exfoliative erythroderma, although its exact mechanism in causing such an exacerbation is not fully understood.

Other drugs rarely reported to exacerbate psoriasis are coniine, a centrally acting alpha adrenergic agent with independent peripheral effects, glibenclamide and tetracycline.

Climate as a Trigger of Psoriasis

Farber and Nell found that 89% of patients in their study experienced worsening of their psoriasis during winter.

High humidity is beneficial, so is gradual tanning sunlight. Harsh sunlight, though, may worsen psoriasis by inducing the Koebner phenomenon through sunburns. Zlotogorski observed that many male patients who drove cars had less involvement of the left elbow than the right one because the left arm was exposed to sunlight through the window.

Winter tends to be the most challenging season for people living with psoriasis. Numerous studies indicate cold weather is a common trigger for many people and that hot and sunny climates appear to clear the skin.

Cold winter weather is dry, and makes the skin drier. This usually worsens psoriasis. Psoriasis can become even more severe when the stress of the holidays and winter illnesses combine to compromise immune systems.

While hot and sunny weather may help clear psoriasis, air-conditioning can dry out the skin and aggravate psoriasis. Regular moisturising and a little humidification of  the interiors can help prevent this.

Smoking as a Trigger of Psoriasis

Several studies confirm that psoriasis is associated with smoking. Nicotine alters a wide range of immunological functions, including innate and adaptive immune responses.

Research suggests that localised (on the palms and soles) pustular psoriasis may be more common in people who smoke tobacco. Other studies suggest a correlation between smoking and developing plaque psoriasis. There also seems to be a link between smoking and developing severe psoriasis.

Quitting smoking improves psoriasis for some; however, quitting does not always clear the psoriasis. More research is needed in this area.

Studies support the hypothesis that nicotine alters the immune response by directly interacting with T cells and dendritic cells as well as indirectly through brain-immune interactions. Additionally, nicotinic cholinergic receptors have been demonstrated on keratinocytes that stimulate calcium influx and accelerate cell differentiation; they can also control keratinocyte adhesion and upward migration in the epidermis. This suggests a biologic explanation for the association between smoking and psoriasis.

Alcohol as a Trigger of Psoriasis

It is now believed that heavy drinking may trigger psoriasis in some people. Heavy drinking also may make treatment less effective. Again, more research is needed.

 The finding with respect to alcoholism may at first seem anomalous, because the aetiology of alcoholism has long been described more in terms of behavioural, socioeconomic, and environmental factors.

However, genetic factors have been implicated in the development of alcoholism, and other studies have similarly described an association between increased alcohol consumption and psoriasis.

One study conducted in the United States reported that patients with psoriasis had a daily alcohol consumption rate averaging of two to three times the national average. Other studies have suggested that alcohol may act as a triggering event and may also adversely affect response to treatment in psoriasis patients.

Diet as a Trigger of Psoriasis

Many claims have been made on the role of diet in triggering or worsening psoriasis. Many scam sites advocate fad diets that are ‘guaranteed’ to ‘cure’ psoriasis. To create pseudo-credibility, they also post many testimonials from patients who have been cured (Just read through those testimonials: most often they all have same style, indicating the same author!)

Well, here is the fact: Current scientific research does not confirm that eating a certain food or taking a specific supplement could make psoriasis better or worse. Though some studies support that psoriasis seems to improve with omega 3 fatty acid containing fish oils, evening primrose oil etc, others have found no appreciable benefits.

There is also no scientific evidence to support the claim that supplements such as grape seed extract, olive leaf extract, Ester C, shark cartilage etc.  benefit psoriasis.

Red meats, which contain arachidonic acid, may exacerbate psoriasis and is best avoided. Arachidonic acid is known to induce inflammation.

Do not ever be under the impression that anything ‘natural’ or ‘herbal’ is harmless! They can have unknown side effects, which could sometimes be dangerous, just like any other medication. The side effects are unknown because they have not undergone the vigorous clinical and laboratory investigations that the modern medicine undergoes. 

Hence it is important to inform your dermatologist what kind of supplement or herbal remedy you are taking and how much you are consuming.

Hormones as a Trigger of Psoriasis

Science has not uncovered all psoriasis triggers. Hormones also appear to trigger psoriasis in some people.

How hormones affect psoriasis is still not well understood. Research shows that many people develop their first psoriatic lesions just after puberty when hormone levels fall. When hormones levels increase during pregnancy, psoriasis improves for many women. A recent study showed that 55% of pregnant women with psoriasis reported an improvement, 21% saw no change, and 23% experienced worsening. After delivery, only 9% reported improvement and 65% saw their psoriasis worsen. More research is needed to understand these effects.

Associated Diseases of Psoriasis

Because psoriasis appears to be a multifactorial disease, some epidemiological surveys have been conducted to determine disease associations in psoriasis as a means of better understanding the pathogenesis of the disease.

Ina study of 159,200 Swedes, 372 patients with psoriasis were identified who had higher rates of viral infections, urticaria, alcoholism, hypertension, pneumonia, hepatic cirrhosis, and rheumatoid arthritis.

Psoriasis also seemed to be more commonly associated with diabetes, obesity, myocardial infarction, and asthma in women than in men, whereas iritis and ankylosing spondylitis were more commonly associated with psoriasis in men.

In most studies, obesity, diabetes mellitus, heart failure, and hypertension were found significantly more frequently in patients with psoriasis, as was chronic tonsillitis.

Several cutaneous disorders including atopic dermatitis, eczema herpeticum, urticaria, impetigo contagiosa, and allergic contact dermatitis were significantly under represented in patients with psoriasis. The diminished frequency of infectious diseases in patients with psoriasis together with a significantly reduced rate of T-cell-dependent disorders such as contact allergy and atopic dermatitis supports the concept that psoriasis is an immuno dysregulatory process.

To sum up, psoriasis is a multifactorial disease with a genetic predisposition, triggered by many lifestyle factors, setting in motion an immune cascade of events resulting in a hyper proliferative disease in the skin and joints.

Read more about Psoriasis

Disclaimer

The information given in this article is for educational purpose only so that patients are aware of the options available for diagnosis and treatment of common skin, hair and nail diseases. No diagnosis should be made or treatment undertaken without first consulting your dermatologist. If you do so, the author will not be responsible for any consequences. The images provided are for illustration purpose only and should not be reproduced without the consent of the author.

About the Author of Skin Care Tips from Dermatologist: Dr Hanish Babu, MD
Dr Hanish Babu, MD, Dermatologist, Sharjah and Ajman, UAE
Dr Hanish Babu, MD

Dr Hanish Babu, MD is a dermatologist with more than 3 decades of experience in treating skin and sexually transmitted diseases in UAE and India. He has been practicing in UAE since last 22 years. He is a respected speaker during the Continuing Medical education Programmes for doctors, medical students and paramedical staff and is also a Stress Management Trainer. He organises group therapy sessions for patients with psoriasis, eczema and vitiligo.

He is available for consultation at Cosmolaser Medical Centre in Samnan, Sharjah (06 5678 200) from 10 am – 2 pm and at City Medical Centre, Al Bustan, Ajman (06-7 441 882) from 4.30 pm – 9.30 pm.

Visit his personal website  dr-hanishbabu.com for more details and for educational articles on Skin, hair, nail and sexually transmitted diseases. Click here to Book an Appointment with dermatologist Dr Hanish Babu, MD

What are the Causes of Psoriasis?

The genetic link of psoriasis has long been known, it tends to run in families. About 30% of people with one first degree relative with psoriasis has chances of developing the disease during their life time.

Just having a close relative with psoriasis does not mean that a person could definitely inherit the disease. This genetic tendency need to be triggered by some environmental, physiological or psychological factors for a person to get psoriasis.

There is no way of predicting who will develop psoriasis and who will not. 50-60% of people who have psoriasis do not know anyone in their family with the disease.

Psoriasis: Causes and Triggers

The exact cause of psoriasis remains a mystery still. As mentioned above, whether a person develops psoriasis or not may depend on a “trigger”. Possible psoriasis triggers include emotional stress, skin injury, climatic changes, systemic infections, alcohol, smoking and certain medications.

Psoriasis patients can develop lesions at the site of skin injury involving the deeper layers of the skin, especially during a period of active disease. Psoriasis worsens in areas of skin scrapes, scratches, and cuts (such as surgical wounds). That’s why it is advisable not to pick or scrub the lesions and scales of psoriasis. The development of a psoriatic lesion at the site of skin injury is known as Koebner’s phenomenon.

What happens in Psoriasis
The Sequence of events in Psoriasis

What Really Happens in Psoriatic Skin?

 It has been suggested that a particular epidermal triggering event induces activation of the basal cell (generating cells) layer of the epidermis through activated T lymphocytes (immune cells) in the blood vessels immediately beneath the epidermis.  This results in increased turnover of epidermal cells which reach the top layer within 3-4 days instead of the normal 28 days. These are the silvery white thick scales, the typical feature of psoriasis.

The Normal Skin Vs Psoriasis Skin

The initial change in psoriasis skin  is the dilatation of  capillaries (small blood vessels in the dermis) and swelling of the papillary dermis, which is that part of the dermis immediately below the epidermis. The inflammation causes round white blood cells called mononuclear cells to crowd around these blood vessels. Some of these cells move into the lower epidermal cells causing mild swelling of the cells there. There is also squirting of neutrophils (another type of white blood cells) by the dilated capillaries into the epidermis, which may form micro abscesses within the epidermal layers.

Microscopic Changes in Psoriasis Skin

In healthy skin, epidermal cells which are formed in the basal layer, are pushed up by newly formed cells from beneath. They move towards the superficial layers, gradually maturing and then getting shed from the skin surface in about 28 days. This is an ongoing process and is not very visible in normal skin (except for the dry scales seen in people with dry skin, especially in cold weather).

In people with psoriasis, due to the immunological and cellular events mentioned above, this process is accelerated to  3 to 5 days. This excessive reproduction causes skin cells to build up and form abnormal scaling seen in psoriasis. The scales seen are actually immature or premature epidermal cells, as they do not get time to mature within 3-5 days. The redness beneath is because of the dilated and tortuous capillaries in the papillary dermis, which becomes exposed due to the loosely adherent scales of psoriasis.

Genetic Basis of Psoriasis

Nickoloff BJ. The Immunologic and Genetic Basisof Psoriasis. Arch Dermatol. 1999;135(9):1104–1110. 

The analysis of population-specific human leukocyte antigen (HLA) MHC Class 1 helio types has provided evidence that susceptibility to psoriasis is linked to the class I andII major histocompatibility complex on human chromosome 6. In addition, these studies show that psoriasis consists of two distinct disease subtypes (type I and type II), which differ in age of onset and in the frequency of HLA. In type I (early-onset) psoriasis, Cw6, B57, and DR7 are strongly increased, whereas in type II (late-onset) psoriasis, HLA-Cw2 is over represented.

The above medical jargon may seem confusing, but what this all means is that if any of the parents have psoriasis, the chances of their children get psoriasis is high, almost 10-25%. If both parents have psoriasis, 50% of chances are there that the children may be affected.

Keep in mind that there are also more than 50-60% cases that do not have any family history of psoriasis.

This means that genetic factors alone do not cause or induce psoriasis. To put in simpler words, you do not inherit psoriasis, but inherit a tendency to get the disease!

Immunological Basis of Psoriasis

Significant evidence is accumulating that psoriasis is an autoimmune disease.

Immunological Events in Psoriasis: The Biological Medications Act at Different Immunological Levels

Lesions of psoriasis are associated with increased activity of T cells in underlying skin. The focus of research has gradually shifted from the keratinocyte to activated immunocytes as the prime cellular culprits in psoriasis. The precise mechanism by which activated T cells trigger psoriasis is unknown, but it may involve release of cytokines that influence the extra cellular matrix and the receptors on the surface of epidermal keratinocytes.

Over the past decade, the view of the pathogenesis of psoriasis has dramatically changed. Previously it was assumed that keratinocyte hyper proliferation associated with abnormal epidermal differentiation was the primary cause of psoriasis. However, it is now recognised that epidermal hyperplasia is a reaction to the activation of the immune system in focal skin regions, which, in turn, is mediated by CD8+ and CD4+ T lymphocytes that accumulate in diseased skin.Indeed, psoriasis is now recognised as the most prevalent T-cell–mediated inflammatory disease in humans.

Now let us examine the Triggers of Psoriasis

Read more about Psoriasis

Dr Hanish Babu, MD, Dermatologist & Venereologist, City Medical Centre Ajman and Cosmolaser Medical Centre, Sharjah, UAE

Disclaimer

The information given in this article is for educational purpose only so that patients are aware of the options available for diagnosis and treatment of common skin, hair and nail diseases. No diagnosis should be made or treatment undertaken without first consulting your dermatologist. If you do so, the author will not be responsible for any consequences. The images provided are for illustration purpose only and should not be reproduced without the consent of the author.

About the Author of Skin Care Tips from Dermatologist: Dr Hanish Babu, MD
Dr Hanish Babu, MD, Dermatologist, Sharjah and Ajman, UAE
Dr Hanish Babu, MD

Dr Hanish Babu, MD is a dermatologist with more than 3 decades of experience in treating skin and sexually transmitted diseases in UAE and India. He has been practicing in UAE since last 22 years. He is a respected speaker during the Continuing Medical education Programmes for doctors, medical students and paramedical staff and is also a Stress Management Trainer. He organises group therapy sessions for patients with psoriasis, eczema and vitiligo.

He is available for consultation at Cosmolaser Medical Centre in Samnan, Sharjah (06 5678 200) from 10 am – 2 pm and at City Medical Centre, Al Bustan, Ajman (06-7 441 882) from 4.30 pm – 9.30 pm.

Visit his personal website  dr-hanishbabu.com for more details and for educational articles on Skin, hair, nail and sexually transmitted diseases. Click here to Book an Appointment with dermatologist Dr Hanish Babu, MD

How Common is Psoriasis?

Psoriasis  is one of the commonest skin diseases . It has the dubious distinction of having second place in prevalence  amongst all skin diseases, the first being acne vulgaris. Psoriasis is also one of the oldest skin diseases known to medical science.

Prevalence of Psoriasis

Global Prevalence of Psoriasis (Greb JE et al. Psoriasis. Nat.Rev.Dis.Primers doi:10.1038/nrdp.2016.82)

Genetic and environmental factors greatly influence the clinical development of psoriasis. This results in wide differences in the prevalence of this disease among different ethnic groups and in different parts of the world.

Patients with minimal clinical manifestations often do not  seek medical attention. In many third world countries, poverty, illiteracy, ignorance, and , in case of females, modesty may be preventing patients from approaching health care providers for diagnosis and management of the disease.Hence psoriasis may be much more prevalent than the studies indicate.

Most studies on prevalence are based on information from clinical examinations, interviews, census studies and mailed questionnaires.

Thus, estimates of the occurrence of psoriasis in different parts of the world vary from 0.1 to 3%.

Around 125 million people worldwide (up to 3% of the population) have psoriasis.

23% of people – that’s28 million – with psoriasis go on to develop psoriatic arthritis, a potentially debilitating type of joint disease, a complication of psoriasis.

Its prevalence in a hospital population was about 6% to 8.7% in two studies

In the United States, between 2 and 2.6% of the population is affected with psoriasis. That works around to approximately 7.5 million persons with psoriasis. Between 150,000 and 260,000 new cases of psoriasis are reported annually.

Four hundred people die annually from psoriasis-related causes in the US.

Approximately1.5 million people with psoriatic arthritis seek medical care each year in theUS.

Geographical & Racial Distribution

Psoriasis is more common in whites. The incidence of psoriasis is much lower in dark-skinned West Africans andAfrican-Americans than in light-skinned people of European ancestry. Incidence is also low in Japanese and Eskimos, and is extremely low to non-existent in Native Americans in both North and South America.

The prevalence of psoriasis in African Americans has been estimated at 0.7% based on 3860 consecutive patients seen in a private dermatology practice in Cleveland, Ohio. Gelfand et al(2005) confirmed these previous investigations that have suggested that psoriasis is less common in African Americans than in Caucasians. However, according to their  study, psoriasis was certainly not rare in African Americans as was previously thought of.  Their study showed the prevalence of psoriasis as 2.5% in Caucasian patients and  1.3% in African American patients.

In Africa, variations in the prevalence of psoriasis have been observed between West African countries such as Nigeria (0.8%) and East African countries such as Kenya (2.6%).

Age of Onset inPsoriasis

Psoriasis occurs in both children and adults and may appear at any age, although it is most commonly diagnosed between the ages of 12 and 35. A second peak appears between the ages of  60 to 69 years.

There have also been case reports of psoriasis appearing in infants within weeks of birth and in patients above the age of 70 years, but these are more of exceptions rather than the norm.

Approximately 10-15% of new cases begin in children younger than 10 years. Children tend to have more of the guttate variety of psoriasis than the plaque psoriasis compared to adults.The median age at onset is 28 years.

Females tend to develop psoriasis slightly earlier than males and those with a family history have an early age of onset.

Sex

Psoriasis occurs with almost equal frequency in males and females. Many studies have found higher prevalence among males while others vouch for a higher female prevalence. As the difference between the genders are not very prominent, we will settle for the equal frequency.

There may be another reason for the disparity in sex prevalence studies.

As females are more concerned about the condition of  skin and nails and are more aesthetically inclined than their counterparts, they must be approaching doctors more often with milder varieties of psoriasis.

Read more about Psoriasis

Psoriasis: A Brief History

Psoriasis is probably one of the longest known illnesses of humans and also one of the most misunderstood one. It was confused with leprosy till the 19th century.

The biblical term ‘lepra’ was actually applied to various cutaneous disorders including psoriasis, vitiligo, eczema, boils and alopecia areata. Some believe that  ‘tzaraat’ mentioned in the Bible represents psoriasis.

Hippocrates (460 – 377 BC) did describe a skin condition akin to psoriasis.

There are mentions in the literature about the term “psoriasis” as being  used by Aristophanes of Byzantium at the end of the third century B.C. But Aristophanes’ description  of the disease does not, however, correspond to our clinical picture of psoriasis.

Some historians, however, believe that  it was the Roman physician Galen who used the term “psoriasis vulgaris” for the first time, though not particularly for the exact entity .

The name psoriasis is derived from the Greek word psora which means to itch. In fact, before Hebra (see below) the term ‘psoriasis’ was used for many skin diseases where itching was a prominent feature.

In the first century, the Roman Sage Cornelius Celsus described a condition similar to psoriasis and classified it as the fourth variant of impetigo.

JosephJacob Plenck (Vienna, 1776) wrote of a condition similar to psoriasis as being amongst the group of desquamative (scaly or scale like) diseases. He did not dig deeper to differentiate it from other dermatological conditions.

Psoriasis was known as Willan’s lepra in the late 18th century after the English dermatologist, Robert Willan (1757 – 1812) recognised the disease as an independent entity. He identified two categories. Leprosa Graecorum was the term he used to describe the condition when the skin had scales. Psora Leprosa described the condition when it became eruptive.

Finally, it was in 1841 Ferdinand Hebra, a Viennese dermatologist improved on Willan’s notes and assigned the name  ‘Psoriasis’ to the disease for the first time in the long history of the disease.  It was Hebra who described the clinical picture of psoriasis as we recognise it today. The hereditary factor of psoriasis was already known by that time.

Psoriasis was further differentiated into specific types and effective remedies discovered during 20th Century.

Read more about Psoriasis

What is Psoriasis

Psoriasis is a non-contagious, genetic skin disease that results when faulty signals in the immune system prompt skin cells to regenerate too quickly, causing red, scaly lesions on the skin. It is now considered an autoimmune disease.

Scalp Psoriasis

Psoriasis is a lifelong disease like diabetes and hypertension. It typically causes dry, red, scaly lesions that can appear anywhere on the body, including the scalp, trunk, extremities and nails. Common areas involved are the extensor aspects like elbows, knees and the trunk.

Psoriasis is not contagious, that means you cannot catch it from someone else, nor can you give it to someone else, unless of course, they are your children.

Psoriasis Hands

The genetic origin means that if one of the parents has psoriasis, children stand a 10 to 25%chance of developing it. If both parents have it the odds for the children increase up to 50%.

The natural course of psoriasis is dotted with periods of waxing and waning. The lesions clear for sometime (called remissions), and, following some triggers, come back again. At times, when a treatment, like potent topical corticosteroids, is withdrawn suddenly, psoriasis may worsen or become generalised. This is known as are bound phenomenon and is something that has to be avoided at all costs.

Psoriasis has no complete cure, but with proper treatment and life style changes, psoriasis can be kept under optimum control and remission so as not to affect the quality of life of the patient.

The absence of a specific cure also means that psoriasis requires life long care and management.

Though there is no cure yet for the disease, recent introduction of new biological therapies has provided a fresh ray of hope for psoriatic patients for a better quality of life ahead. What is unique about biologic treatments is that they pinpoint certain immune responses that are involved in psoriasis, not the entire immune system, thereby creating fewer side effects for the patient and less damage to the immune system as a whole.

Read More about Psoriasis

Psoriasis 101

All about Psoriasis

This is a short introduction to Psoriasis, the first of a series of educational articles on psoriasis by Dr Hanish Babu, MD, Dermatologist, City Medical Centre, Ajman and Cosmolaser Medical Centre Sharjah, UAE. Visit his home page to book an appointment.

Please bookmark this page and come back for more articles, the links are given below, which will be updated periodically. 
Psoriasis plaques on hand
Psoriasis: A Chronic Scaly Skin Condition
  1. Psoriasis is a chronic dry, scaly skin condition for which no cure has yet been found.
  2. Psoriasis is derived from the Greek word ‘psora’, which means itch.
  3. Psoriasis is not contagious.
  4. Psoriasis has a genetic basis, whereby in predisposed individuals certain triggering events or factors induce the body’s immune system to mistakenly speed up the growth cycle of skin cells.
  5. 125 million people worldwide (up to 3% of the population) have psoriasis. According to National Institute of Health, there are more than 7.5 million psoriasis patients in the United States.
  6. 10-30% of people with psoriasis may develop psoriatic arthritis with inflamed, stiff and painful joints.
  7. Studies have shown that people with psoriasis have almost the same reduction in quality of life as people with diseases such as cancer, diabetes or depression.
  8. Treatment for psoriasis is both topical and systemic and the choice and outcome of these treatments varies from individual to individual. Many patients suffer psoriasis in silence due to improper diagnosis and treatment.
  9. Most patients with psoriasis/psoriatic arthritis avoid social activities requiring body exposure due to embarrassment and fear of rejection.
  10. Recently, new biological therapies have been introduced giving new hope to people with psoriasis.

Read more about Psoriasis:

Topical Corticosteroids: Double Edged Swords!

Topical corticosteroids have revolutionised the treatment of inflammatory skin diseases, since they were introduced in 1952. They are very effective treatment options for many skin diseases and have revolutionised the management of eczema, allergies and other inflammatory skin diseases like psoriasis. Their effectiveness is prompt and most acute allergies can be cured within a few days. For chronic illnesses, like Atopic Eczema in children and psoriasis, they have to be used for a longer duration.

But, If not used with proper titre of dose and strength, they can cause damage to the skin, sometimes permanent. There are many unscientific formulations masquerading as anti-fungal creams and whitening or bleaching creams in the market, where one of the ingredient is potent or super potent steroid. Thus topical steroid creams are double edged swords, the use of which should be carefully titred according to their potency, stage of disease, age of the patient and site of application.

A knowledge of different classes of topical steroids according to their potency is important for everyone prescribing or using these effective and useful medications.

Classes of Steroids and Precautions
Classes of Steroids and Precautions

From the above it is clear that  topical corticosteroids  should be carefully chosen according to their potency, stage of disease, age of the patient and site of application. This is of paramount importance and all those who use these wonderful medications, including patients, pharmacists and doctors should be aware of their strengths and indications of use.

Topical corticosteroids come in several forms, including creams, lotions and ointments. Creams and solutions are a class below in potency than ointments. Ointments are greasy and preferred in chronic dermatitis and scaly diseases like psoriasis. Creams can be used in acute and subacute skin inflammation. Gels and lotions are preferred in hairy areas and scalp.

Side Effects of Topical Corticosteroids

Topical steroids have both topical (limited to skin) and systemic side effects.

Topical Side Effects of Topical Steroids Limited to Skin
  • Topical application of steroids causes thinning of the skin by causing atrophy of the skin layers.
  • Dilation of capillaries that are shown through the thinned skin, known as telengiectasia.
  • Stretching and splitting of the skin causing stretch marks or striae dystensiae.
  • Pimple like eruptions on the treated area, especially on the face, chest, back and limbs, called steroid acne.
  • The main problem with topical (and systemic steroids) is the rebound phenomenon or exacerbation of the lesions that occur if the steroids are suddenly stopped or withdrawn. A localized form of psoriasis can become generalized or a generalized form can get precipitated as pustular or erythrodermic forms when steroids are withdrawn.
  • Higher strength steroids should be avoided on the face, especially near eyes, on the body folds and near the genital organs. Steroids used near eyes for prolonged duration have been shown to cause cataract formation in the eyes and glaucoma.
  • Steroids are best avoided in the presence of infection as these can exacerbate infections.
  • Other topical side effects of topical steroids include easy bruising, purpura, skin ulceration, non healing of ulcers, exacerbation of infections, perioral dermatitis, rosacea, hypo pigmentation, hyper pigmentation, and excessive hair growth. Mistaken application of steroids on ring worms cause changes in morphology and spread of the fungal infection, known as tinea incognito.
Systemic Side Effects of Topical Steroids
  • Adrenal Suppression. Because of the absorption of potent steroids into the blood stream, the adrenal glands could become suppressed and their production of normal steroids will suffer as a result. This can have far reaching effects on the body. If prolonged, this can produce a cushingoid (moon like) face in patients and cause other systemic effects.
  • Tachyphylaxis.The body develops resistance to the topical application after some time.
How to Avoid Topical Steroid Side Effects
Unscientific Steroid Combinations
Unscientific Steroid Combinations are better avoided
  1. Topical Steroids are wonder drugs for many skin diseases like eczema and skin allergies but should be used only under supervision of a skin specialist or a modern medicine doctor who is trained to use it.
  2. Never buy steroid containing creams directly from pharmacy
  3. Avoid using fairness, whitening or bleaching creams from saloons, parlours and unlabelled sources. These may contain very strong steroids and cause serious damage to your skin.
  4. Avoid using so called anti-fungal creams containing steroids. When in doubt, consult a skin specialist before using such creams.
  5. Potent and super-potent steroid creams should only be used under the supervision of a skin specialist.
  6. Never use steroid containing creams in the presence of infection or if diagnosis is not sure.
  7. Use appropriate graded strength according to severity, age, site of involvement.
  8. Gradual withdrawal and replacement with safer creams should be resorted to.
  9. Superpotentà Potent à Moderate à Least Potent.  Shift down as the condition improves.
  10. Application free interval: 5-7 days after every two weeks of application helps avoid side effects.
  11. Never use higher strength topical steroids in infants and children.
  12. Avoid moderate to superpotent classes of topical steroids in sensitive areas like face and body folds.
  13. Once acute phase is under control, shift to steroid sparing calcineurin inhibitors like Tacrolimus, Pimecrolimus.
Disclaimer

The information given in this article is for educational purpose only so that patients are aware of the options available for diagnosis and treatment of common skin, hair and nail diseases. No diagnosis should be made or treatment undertaken without first consulting your dermatologist. If you do so, the author will not be responsible for any consequences. The images provided are for illustration purpose only and should not be reproduced without the consent of the author.

About the Author of Skin Care Tips from Dermatologist: Dr Hanish Babu, MD
Dr Hanish Babu, MD, Dermatologist, Sharjah and Ajman, UAE
Dr Hanish Babu, MD

Dr Hanish Babu, MD is a dermatologist with more than 3 decades of experience in treating skin and sexually transmitted diseases in UAE and India. He has been practicing in UAE since last 22 years. He is a respected speaker during the Continuing Medical education Programmes for doctors, medical students and paramedical staff and is also a Stress Management Trainer. He organises group therapy sessions for patients with psoriasis, eczema and vitiligo.

He is available for consultation at Cosmolaser Medical Centre in Samnan, Sharjah (06 5678 200) from 10 am – 2 pm and at City Medical Centre, Al Bustan, Ajman (06-7 441 882) from 4.30 pm – 9.30 pm.

Visit his personal website  dr-hanishbabu.com for more details and for educational articles on Skin, hair, nail and sexually transmitted diseases. Click here to Book an Appointment with dermatologist Dr Hanish Babu, MD

Acne Scars: FAQ

Frequently asked questions on Acne Scars will clarify your doubts on how to get rid of acne scars.

Acne Scars : FAQ
Acne Scars: Better Prevented!
1. Acne Scars FAQ: What is a Scar?  
  Scar is a collection of new connective tissue. In the skin scar implies damage to both epidermal and dermal layers. If there is more deposition of connective tissue (collagen), the scar is known as hypertrophic scar. These scars are initially red, raised, firm, and, at times, itchy and painful. If the skin heals with the least amount of collagen, this is known as atrophic scar. Atrophic scars are shiny and papery thin to the touch.  
     
2. Acne Scars FAQ: How is Acne Scars Formed?  
  Acne scars are caused by healing of inflamed acne lesions. Skin repairs itself after any injury, including inflammation, by generating new collagen underneath. This deposition of new connective tissue causes acne scar (see above). The main cause of acne scar is uncontrolled disease activity causing continuous inflammatory response within the dermis. The damaged skin repairs itself with scarring.
Learn how acne scars are formed.
 
     
3.   Acne Scars FAQ: I have a face full  of acne scars and dark spots. My friend also had acne, but now has a clear face! Why do some people get acne scars and others do not?  
  How and why some people get scar and others do not is not completely understood. The following may be the reasons: Some people may be more prone for acne scar than others They may be genetically predisposed to get scars: getting scars, not only the acne ones but the regular scars as well, runs in the family! People who have severe and very severe types of acne(the deep nodulo-cystic variety of acne), where the inflammation is not controlled properly and in time, can have deeper and pronounced acne scars. Picking at the acne lesions with nails or pins increase the chances of  scarring in acne.
Read more about acne scar causes.
 
     
4. Acne Scars FAQ: How to avoid getting acne scars?  
  The single most important way to avoid scarring is to effectively treat the acne before it worsens and causes severe inflammation. The more the inflammation, the deeper and larger will be the scar. So taking steps in generally limiting the inflammation at its early stage is very important to avoid getting acne scars. Also avoid irritating the acne lesions by constantly picking at the lesions.
Read more about Why Preventing Acne Scars is Better than Cure.
 
     
5. Acne Scars FAQ: What are the Types of Acne Scars?  
  There are many types of acne scars. The type, size and texture of scars differ according to the  following factors:
Type of skin: The oilier, more severe
Type of acne: The more inflamed, the deeper and firmer the scars Extend of acne: The deeper the lesions, the deeper the scar.
Type of treatment received: Systemic medication, if taken early in the disease state can Keloid ( a type of uncontrolled hypertrophic scar) tendency runs in families. Individuals with this tendency will have larger, thicker and raised scars. 
Read more on Types of acne scars.
 
     
6. Acne Scars FAQ: Can I start my acne scar treatment while I am on accutane treatment?  
  Harsh topical treatment and laser treatments should not be performed while on accutane. You should wait at least 6 months after accutane is stopped to treat your scar. Some studies have pointed out that actuate causes more scarring in some individuals. But these are not conclusive as accutane treatment is taken for severe and very severe types of inflamed and nodulocystic acne, which otherwise also heal with scarring, with or without scarring.
 
     
7.   Acne Scars FAQ: I used to have pimples earlier. Now i am 26 yrs and I have marks left over by them. How can I clear those marks.  
  Your question is not very clear. Do you have only marks (blemishes) or actual scars? The treatment differs for each, evidently. Please read more about acne blemish treatment and acne scar treatment.  
Acne Scar: Frequently Asked Questions: Related Articles
Disclaimer

The information given in this article is for educational purpose only so that patients are aware of the options available for diagnosis and treatment of common skin, hair and nail diseases. No diagnosis should be made or treatment undertaken without first consulting your dermatologist. If you do so, the author will not be responsible for any consequences. The images provided are for illustration purpose only and should not be reproduced without the consent of the author.

About the Author of Skin Care Tips from Dermatologist: Dr Hanish Babu, MD
Dr Hanish Babu, MD, Dermatologist, Sharjah and Ajman, UAE
Dr Hanish Babu, MD

Dr Hanish Babu, MD is a dermatologist with more than 3 decades of experience in treating skin and sexually transmitted diseases in UAE and India. He has been practicing in UAE since last 22 years. He is a respected speaker during the Continuing Medical education Programmes for doctors, medical students and paramedical staff and is also a Stress Management Trainer. He organises group therapy sessions for patients with psoriasis, eczema and vitiligo.

He is available for consultation at Cosmolaser Medical Centre in Samnan, Sharjah (06 5678 200) from 9 am – 1 pm and at City Medical Centre, Al Bustan, Ajman (06-7 441 882) from 4.30 pm – 9.30 pm.

Visit his personal website  dr-hanishbabu.com for more details and for educational articles on Skin, hair, nail and sexually transmitted diseases. Click here to Book an Appointment with dermatologist Dr Hanish Babu, MD