**1. Introduction**

78 Psoriasis

Verstappen, S. M., Jacobs, J. W., van der Veen, M. J., Heurkens, A. H., Schenk, Y., ter Borg, E.

Verstappen, S. M., Watson, K. D., Lunt, M., McGrother, K., Symmons, D. P., & Hyrich, K. L.

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(2010). Working status in patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis: results from the British Society for Rheumatology Biologics

(ASAS) classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general: the spondyloarthritis concept in progress. *Ann Rheum* 

Hinueber, U., Wassenberg, S., Genth, E., & Schneider, M. (2006). Healthcare and burden of disease in psoriatic arthritis. A comparison with rheumatoid arthritis and

Vasey, F. E., L.R. (1984). Psoriatic arthropathy. Orlando, Grune & Stratton.

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ankylosing spondylitis. *J Rheumatol* 33(1), pp. 86-90.

*Dis* 66(11), pp. 1443-1449.

*Dis* 70(1), pp. 1-3.

Psoriasis is an immuno-mediated condition whose pathogenesis is still unclear and that in head and neck area presents six specific aspects that justify the title of this chapter: 1) visibility of the lesions and their impact on quality of life (QOL); 2) the very common involvement of the scalp; 3) the difficulty of the treatment; 4) the aberrant epidermalmesenchymal interactions theory; 5) the rare mucous occurrence and the PPP-tonsil-related disease; 6) the significantly increased risk of head and neck cancer in men with Psoriasis.

#### **2. Visibility and the impact on quality of life**

Visibility of head and neck Psoriasis has a considerable impact on patients' QOL. The differential diagnosis for pustular skin disorders is extensive but facial Psoriasis more commonly affects eyebrows, the skin between the nose and the upper lip, the upper forehead and the hairline. Scalp Psoriasis is very common. Multiple instruments have been used to determine the severity of scalp Psoriasis and tools for patient self-assessment have also been developed (Psoriasis Area and Severity Index or PASI, Psoriasis Scalp Severity Index or PSSI, Body Surface Area or BSA, Physicians' Global Assessment or PGA, Lattice Physician Global Assessment or LS-PGA, and Self-assessed Psoriasis Area and Severity Index or SAPASI) but none of the severity scores used for Psoriasis meets all of the validation criteria required for an ideal score. However the PASI score is the most extensively studied (Puzenat & al, 2010).

While head represents only 10% of the whole body's surface, consequences of scalp Psoriasis are disproportionate to its extension as it can be seriously debilitating inducing important social and emotional distress.

Although it is unclear why initial scalp involvement is so common, scalp tissue has unique features that may promote its vulnerability to psoriatic lesions. For example, its high follicular density provides a dark, warm and moist environment that reduces environmental UV exposure which normally would limit lesion development. In addition, inflammation-

Head and Neck Psoriasis 81

respectively than those without Psoriasis (even after adjustment for classical risk factors of

The data analysis suggests that a minimum of two summary scores (one for skin and one for joints), and potentially a third for nails, are required to accurately assess severity across the full spectrum of psoriatic disease. The optimal design of such assessment tools remains the objective of many research projects, with efforts continuing to identify the most meaningful contributing elements that define the full spectrum of the psoriatic disease state (Wittkowski

Association between Psoriasis and addictive disorders is a longtime suspect and several studies are supporting association of Psoriasis and alcohol, and of Psoriasis and tobacco. Association between Psoriasis and alcohol seems not to be influenced by gender and shows a dose-effect relation. The most striking link between cigarette smoking and Psoriasis has been established in Palmo-Plantar Pustulosis (PPP). This link also seems to exist for other

The relationship between cigarette smoking and Psoriasis has been the subject of several studies. It was showed that cigarette smoking represents a significant risk factor for appearance of Psoriasis, especially in women, in a case about five, and it has been pointed out that risk increases with the number of cigarettes consumed per day and increases in those who smoke 20 or more daily. The risk would increase further in those who have a family history of this disease. Also for PPP seems to be a relation to cigarette smoking, with a risk factor 7.2 times higher in smokers than in non smokers. The report is based on leukocyte neutrophil counts: PPP is a neutrophilic dermatosis and cigarette smoke increases

Cigarette smoking may be involved in the high prevalence of lung and oral cancer and cardio-vascular disorders in psoriatic patients. The association between alcohol and development of plaque-type Psoriasis is complex and confusing because many of the initial

There are a number of difficulties in the assessment of the correlation between Psoriasis, cigarette smoking and alcohol, and even more so in establishing a causal or etiologic relationship between the three because of several confusing factors (Meyer &al., 2008).

Alcohol-controlled studies suggest that women who are smokers have an up to 3.3-fold increased risk of developing plaque-type Psoriasis. Men who are smokers do not exhibit such an increased risk, but studies have shown that smoking more than 10 cigarettes per day by men who are Psoriasis patients may be associated with a more severe expression of disease in their extremities. In addition, smoking among both men and women who are

Dermatologists are not only the sentinels for early diagnosis of psoriatic arthritis, but also for metabolic complications such as dyslipidemia or diabetes. Moreover, they need to keep in mind interactions between (systemic) anti-psoriatic drugs and the co-medication of their patients as well as possible consequences of these co-medications on the course of Psoriasis

peripheral neutrophil counts and alters it in morphological and functional way.

studies did not control for confounding factors such as tobacco use.

Psoriasis patients has been shown to reduce improvement rates.

(Behnam & al., 2005).

mortality). Hence Psoriasis is a major public health problem.

& al., 2011).

**2.1 Addictions and Psoriasis** 

forms of Psoriasis with a dose-effect relation.

promoting microorganisms flourish in the sebum-rich setting of the scalp and, as seen in one study, an association with the severity of scalp disease was suggested to be related to isolation of Malassezia globosa yeast from patients scalp (Gupta & al., 2004).

Additional inflammation may be triggered or exacerbated by frequent friction and trauma to the scalp (Koebner phenomenon: psoriatic lesions as consequence of trauma in psoriatic patients) from brushing or use of styling implements.

Psoriasis of the eye is extremely rare. When it does occur, it can cause inflammation, dryness and discomfort. It may cause vision impairment. When Psoriasis affects the eyelids, scales may cover lashes and topical antibiotics may be used to treat infection.

Psoriasis generally affects the external auditory canal without involvement of the ear or behind the eardrum but can cause scale buildup that can block the auditory canal with subsequent temporary hearing loss.

Rarely Psoriasis appears on the gums, the tongue, inside the cheek and the nose or on the lips. The lesions in these areas are usually white or gray and can be relatively uncomfortable as they can cause chewing and swallowing discomfort.

When Psoriasis involves the face, it can be much more disabling and can severily decrease patient's QOL. Facial Psoriasis is difficult to treat and is associated with severe cutaneous disease. In fact, patients who have a long history of Psoriasis or an early age of onset are more likely to suffer from facial involvement. Facial Psoriasis may also be associated with pruritus, psoriatic arthritis, and with a family history of Psoriasis.

Various clinical manifestations of Psoriasis make it more than a dermatological nuisance, as it interferes with many normal daily activities, such as use of hands, walking, sleeping, and sexual activity. At least 30% of patients contemplate suicide, which places Psoriasis on par with other major medical diseases such as depression, heart disease and diabetes (Krueger, 2001).

Alexithymia was originally defined as the inability to recognize and verbalize emotions. It is characterized by an emptiness of feelings, poverty of imagination or of a life fantasy and by difficulties in communicating with other peoples, as well as lack of positive emotions and a high prevalence of negative emotions. Its presence has been incriminated in genesis and maintenance of various psychosomatic pathologies.

As patient's psychological dimension seems to be related to the onset of the illness, to its evolution and to its prognosis, Psoriasis is classified among psychosomatic pathologies too.

In this perspective Alexithymia does not appear to be simply a condition related to Psoriasis, but a worsening of patient's condition, exposing him to other psychosomatic diseases and alcoholism and to a worsening of his global prognosis. That's why psychological approach in treatment favouring expression of patient's emotions and opening a symbolic dimension is as important as the biological approach and is necessary for improvement (Masmoudi, 2009).

A recent cohort study (Gelfand & al., 2011) has also shown that severe Psoriasis (defined as Psoriasis patients with a history of systemic therapy) is associated with an increased risk of mortality as male and female patients in the study died 3.5 and 4.4 years younger

promoting microorganisms flourish in the sebum-rich setting of the scalp and, as seen in one study, an association with the severity of scalp disease was suggested to be related to

Additional inflammation may be triggered or exacerbated by frequent friction and trauma to the scalp (Koebner phenomenon: psoriatic lesions as consequence of trauma in psoriatic

Psoriasis of the eye is extremely rare. When it does occur, it can cause inflammation, dryness and discomfort. It may cause vision impairment. When Psoriasis affects the eyelids,

Psoriasis generally affects the external auditory canal without involvement of the ear or behind the eardrum but can cause scale buildup that can block the auditory canal with

Rarely Psoriasis appears on the gums, the tongue, inside the cheek and the nose or on the lips. The lesions in these areas are usually white or gray and can be relatively uncomfortable

When Psoriasis involves the face, it can be much more disabling and can severily decrease patient's QOL. Facial Psoriasis is difficult to treat and is associated with severe cutaneous disease. In fact, patients who have a long history of Psoriasis or an early age of onset are more likely to suffer from facial involvement. Facial Psoriasis may also be associated with

Various clinical manifestations of Psoriasis make it more than a dermatological nuisance, as it interferes with many normal daily activities, such as use of hands, walking, sleeping, and sexual activity. At least 30% of patients contemplate suicide, which places Psoriasis on par with other major medical diseases such as depression, heart disease and diabetes (Krueger,

Alexithymia was originally defined as the inability to recognize and verbalize emotions. It is characterized by an emptiness of feelings, poverty of imagination or of a life fantasy and by difficulties in communicating with other peoples, as well as lack of positive emotions and a high prevalence of negative emotions. Its presence has been incriminated in genesis and

As patient's psychological dimension seems to be related to the onset of the illness, to its evolution and to its prognosis, Psoriasis is classified among psychosomatic pathologies too. In this perspective Alexithymia does not appear to be simply a condition related to Psoriasis, but a worsening of patient's condition, exposing him to other psychosomatic diseases and alcoholism and to a worsening of his global prognosis. That's why psychological approach in treatment favouring expression of patient's emotions and opening a symbolic dimension is as important as the biological approach and is necessary

A recent cohort study (Gelfand & al., 2011) has also shown that severe Psoriasis (defined as Psoriasis patients with a history of systemic therapy) is associated with an increased risk of mortality as male and female patients in the study died 3.5 and 4.4 years younger

isolation of Malassezia globosa yeast from patients scalp (Gupta & al., 2004).

scales may cover lashes and topical antibiotics may be used to treat infection.

patients) from brushing or use of styling implements.

as they can cause chewing and swallowing discomfort.

maintenance of various psychosomatic pathologies.

for improvement (Masmoudi, 2009).

pruritus, psoriatic arthritis, and with a family history of Psoriasis.

subsequent temporary hearing loss.

2001).

respectively than those without Psoriasis (even after adjustment for classical risk factors of mortality). Hence Psoriasis is a major public health problem.

The data analysis suggests that a minimum of two summary scores (one for skin and one for joints), and potentially a third for nails, are required to accurately assess severity across the full spectrum of psoriatic disease. The optimal design of such assessment tools remains the objective of many research projects, with efforts continuing to identify the most meaningful contributing elements that define the full spectrum of the psoriatic disease state (Wittkowski & al., 2011).
