When our defence system fails

Autoimmune diseases are not only part of the daily practice of dermatologists. The skin care professional is also confronted with psoriasis or white spot disease in certain cases and can provide support for the respective client. Professional knowledge is key, safe handling of the skin and deciding when a doctor should be consulted is essential.

In autoimmune diseases, the immune system fights against the body’s own cells and tissues due to misdirected information. Three autoimmune diseases will be observed here today.

1. Psoriasis vulgaris

Triggers and symptoms
Psoriasis is a chronic inflammatory, non-contagious systemic disease, that can affect not only the skin but also other parts of the body (e.g. nails, joints, intestines) and manifests in flare-ups. Approximately two percent of the population in Germany are affected by this condition. Psoriasis can occur at any age, however there are two age peaks: the second to third decade of life and, less frequently, from the fifth decade of life onwards. The cause is a malfunction of the immune system, which results in an inflammatory reaction and a thickening and excessive cell division of the uppermost skin layer. The skin shows sharply defined inflammatory, reddened, raised areas (plaques) with firmly adhering white-silvery scaling. The skin of those affected renews itself much more quickly than normal (three to five days instead of 28 days), which leads to the strong keratinisation in the form of the typical silvery-white scaling. The preferred locations of the plaques are the extensor sides of the arms and legs, especially on the elbows and knees, as well as on the lower back (psoriasis vulgaris).

“With psoriasis, the following applies to skin care: as low in irritants as possible.”

There are also different types of psoriasis, so the scalp (psoriasis capitis), the genital area (psoriasis inversa) or the nails can also be affected.
Characteristic signs are a strong itching sensation (pruritus) of the affected skin. The disease is based on a genetic predisposition.

In addition, there are external triggers that can cause the disease to break out or worsen: external mechanical stimuli of the skin, sunburn, medications (for example, blood pressure reducers, painkillers), nicotine, alcohol, overweight, stress and bacterial infections. Sunlight and heat have a positive effect, therefore often visible improvement of the symptoms occurs in the summer months.

Research has shown that the inflammatory processes in psoriasis also take place internally. Patients can develop inflammation of the joints (psoriatic arthritis), among other things, and psoriatic patients are more likely to suffer from inflammatory bowel disease, high blood pressure, cardiovascular disease, elevated blood lipid levels and diabetes mellitus. Since the skin changes are visible, they often cause a great deal of suffering for those affected. The disease can be very stressful and lead to a reduced quality of life and depression.

Medical treatment
Psoriasis is a serious condition and should definitely be treated dermatologically because of the many co-factors involved. The good news is that there are modern and effective treatments available to treat this condition. Generally speaking, the principle of treatment is to suppress the immune system or to have an anti- inflammatory mode of action.

Psoriasis can be treated with locally applied cortisone preparations (ointments, creams). In addition, vitamin D3 variants are also used for anti-inflammatory local therapy. Light therapy (e.g. UV-B or UV-A) can also be carried out for a limited period of time, as it also has an anti-inflammatory and inhibitory effect on the cell division rate of the epidermis. Severe forms, in which a large part of the body surface is affected or which occur in particular localisations, are treated internally with prescribed pills or injections.

Accompanying care

In addition to the medical therapies cosmetics can be of great importance and help for the affected skin. The rule here is: as low in irritants as possible. Therefore, products that are especially suitable for sensitive skin are recommended. Skin cleansing should be accompanied with moisturising, soap-free washing additives or oil baths without fragrances. Dermatological, low-irritant bases, for example with urea, can optimise the effect of external medicines. The richness of the products depends on how dry the skin is overall, and may well differ in summer (more moisture-rich) and winter (more oil-rich). The desquamation (keratolysis) of the skin can be cosmetically supported very effectively with creams containing salicylic acid in different concentrations, which, in addition to the keratolytic effect, also have slight anti-inflammatory effects.

2. Vitiligo

Triggers and symptoms
The immune system attacks the pigment cells (melanocytes) of the skin and as a result these pigment cells are being destroyed. That causes a depigmentation of the skin, which appears as sharply delineated white patches (white spot disease). It usually occurs between the ages of 10 and 30. Rather interestingly, darker skin types are affected more often than lighter ones. A distinction is made between different forms. Most often, Vitiligo occurs symmetrically and starts around the body orifices, especially around the eyes and mouth. However, it can also occur on the end phalanges of the fingers or hands, on the trunk of the body, the genital area and even on the mucous membranes, individual strands of hair or eyelashes. The symptoms of the disease are very individual, from single episodes to a continuous increase in the size of the spots to standstill. Similar to psoriasis, a strong visibility of the Vitiligo foci is responsible for a strong psychological burden for the affected person. The causes of Vitiligo are not yet fully understood, but there is a certain hereditary predisposition. Other triggers are stress and various medications (blood pressure medication, blood lipid-lowering drugs and antibiotics). There are also triggering irritant effects. Vitiligo often occurs with other autoimmune diseases, for example, autoimmune thyroid disease (Hashimoto’s thyroiditis) or circular hair loss (alopecia areata). It is striking that patients with Vitiligo are more likely to develop black skin cancer.

Medical treatment
The therapy is not easy and is often tedious. The primary goal is to achieve a permanent repigmentation of the skin, but this expectation is rarely fulfilled. Therefore, it can often be considered a therapeutic success if existing spots do not increase in size. The choice of therapy always takes into account the degree of severity, the activity of the disease and the level of suffering. Initial, localised spots can be treated with externally applied cortisone preparations over a period of time.
Subsequently, local cortisone substitutes (calcineurin inhibitors) are used. In moderately severe forms of the disease UV-B therapy or laser therapy (excimer laser) can be carried out. In severe cases, additional treatment is given internally with cortisone or other immune-suppressing drugs.

Accompanying care
Vitiligo is primarily a visual, cosmetic problem for those affected. Strongly covering make-up (camouflage) can be used to match the rest of the skin tone, and the Vitiligo is less visible. Self-tanning lotions can also help. It is very important to use a consistent and high level of light protection, as the absence of pigments makes the skin very sensitive to UV rays.

3. Scleroderma

Triggers and symptoms
The disease (Greek skleros = hard, derma = skin) is mainly characterised by an increasing hardening of the connective tissue. A distinction is made between localised (circumscribed) and systemic form with organ involvement. Overall it is a rare disease with many different forms.
In circumscritic scleroderma, individual areas of the skin typically harden, which is very disturbing and restrictive for the patient (especially in joint areas), but not life-threatening. Women suffer from the disease significantly more often than men. At first, one or more relatively sharply defined roundish-oval reddenings of the skin, some of which can be enlarged, appear as an expression of the inflammation of the skin and the subcutaneous fatty tissue.
Increasingly, the areas become white or reddish-brown and harden due to an increase in connective tissue at the expense of the subcutaneous fatty tissue. Then you often see a white or yellowish centre of the affected skin region, a white or yellowish hairless plate with a surrounding ring-shaped blue-violet ring (lilac ring). These plaques occur preferentially on areas of the skin where pressure is applied (belts, backpack straps, bra straps, etc.). Therefore, the cause of the pressure should be eliminated (loose clothing, etc.) to prevent or reduce the progression of the disease.
The course of the disease extends over several years, after which there is a resting state, in which the indurations remain unchanged on the skin. The exact triggers of the disease are not known, but it is increasingly regarded as an autoimmunological disease. Genetic, hormonal, medicinal and infectious (especially with Borrelia bacteria) factors are being considered and discussed as triggers, but so far a causal connection has not been proven.

Medical treatment
There is no fundamental cure, but the course of the disease can be
improved by some treatments. Cortisone preparations, cortisone substitutes or variants of vitamin D3 can be applied locally. Phototherapy with UV-A radiation can have a good effect on the deeper inflammatory processes of the skin. In the case of a severe course, internal anti-inflammatory or immune system- suppressing drugs are prescribed. Massages and physiotherapy have a supporting effect.

Accompanying care
The hardened skin should be regularly moisturised with greasy creams.
This protects the skin barrier, the elasticity of the skin is maintained and the increasing tightness of the skin is relieved. Oil-containing baths also help to relieve skin tension. The use of sunscreen is obligatory, as the tanning of the surrounding skin makes the pathological skin changes particularly visible. The regular manual lymphatic drainage by a skin care professional is also considered as helpful.