What is psoriasis and why does it happen?
Psoriasis is an auto-immune condition, this is a condition in which the body's immune system mistakes its own healthy skin cells as foreign and attacks them. The exact cause is still not clear. In psoriasis the dysfunction of the immune system causes inflammation in the body that specifically affects the skin.
Inflammation occurs because the overactive immune system speeds up the growth of skin cells. Typically, normal skin cells completely grow and fall off, or ‘shed’, in a month. However, with psoriasis skin cells do this in only three or four days. The skin cells, instead of shedding, they pile up on the surface of the skin. Some people report that psoriasis plaques itch, burn, and sting. Plaques and scales may appear on any part of the body, although they most commonly appear on the elbows, knees, and scalp.
What are the symptoms of psoriasis?
In psoriasis there may be visible signs of inflammation on the skin, such as raised plaques and scales on the skin. When there are plaques, these may look different in people with different skin types. Plaques can form because of trauma to the skin, such as cuts, grazes, and wounds.
Psoriasis sometimes affects the torso. This may potentially influence the outcome after top surgery. This is because, as discussed, plaques can form as a result of trauma to the skin, which includes surgical wounds.
Does psoriasis affect top surgery?
Suffering from psoriasis does not exclude people from having top surgery, as long as there are balanced expectations. Top surgery is a major operation, and it might affect someone’s immune system. This is because after any surgery, the body is using most of its resources to heal. If surgery affects the immune system, this in turn may trigger a flare-up of psoriasis. Psoriasis or a psoriatic flare-up should not affect the “flatness” achieved. However, psoriasis plaques may form on scars, which results in coloured and raised scars.
When there is history of psoriasis and when preparing for top surgery, the surgeon and the patient should work together to have the procedure when the condition is least active or in remission. For those patients where psoriasis is more seasonally prominent, for example, in winter due to the lack of sunlight, the patient and the surgeon should schedule the operation around a personalised “ideal” timing. However, this is not always possible. Psoriasis typically appears for the first time between the age of 15 and 25 years. Most patients have the condition for some years and will be aware of potential trigger factors. Whenever possible, the patient should try to minimize these trigger factors, e.g., stress/anxiety, alcohol consumption, smoking.
Looking after the skin pre-operatively might also help. A moisturizing routine, using medicated topical treatments (as advised by a doctor) and minimising binding (less sweating and skin stretch) will likely have a positive impact on the overall skin condition. Exposure to sunlight has been shown to help improve the presence and severity of psoriasis plaques on the skin during hotter months. However, whenever there is sun exposure, the patient should take the usual necessary precautions, such as wearing sunscreen and protecting the new scar line from direct sunlight.
Topical steroids are sometimes used to treat the skin. It is especially important that topical steroids should be used with caution on plaques that have formed on scars, because steroids may affect the rate of healing. Steroids have also been proven to thin the skin and discolour psoriatic patches. The appearance of psoriatic skin lesions can be dramatic, and there should be an open dialogue between the patient and the surgeon, so they both remain informed, and the patient is reassured. Outside the scar area, healthy skin can be treated with any usual regime, including topical steroids. Systemic steroids should probably be avoided as they affect the whole immune response and can increase the risk of complications for surgery and the results. Complications can include reduced healing rate with delayed healing, and increased risk of infection.
Topical care after surgery, with massaging the scars using a gentle moisturiser may prevent hypertrophy and should not worsen the development of psoriasis. Scar care products should be considered outside the acute phase of psoriasis.
After the operation, a balanced diet and a stress-free environment could also help. As with all major operations, ensuring hydration and looking after someone’s self are important.
If psoriasis develops after top surgery, a smooth communication between the patient and the surgeon – but also a dermatologist – will mitigate the patient’s anxiety and help formulate a concrete plan. The timeline of psoriasis and flare-ups is not exact, and as such, there is no exact timeframe for following up; a watch and adjust approach is the most reasonable and wanted way aiming always to patient support and reassurance. It would be wise for a patient to discuss and consider a suitable management plan with their surgeon and GP/dermatologist both before and after surgery.
A patient with psoriasis who has had top surgery shares his experience
Below is an example of a patient with chronically active psoriasis, who was diagnosed when he was 6 years old. He is sharing his journey related to top surgery with the following photographs:
Important to remember
1. Psoriasis, what is it?
Psoriasis is a condition in which the body's immune system mistakes its own healthy skin cells as foreign and attacks them. The exact cause is still not clear.
2. What to consider if there is history of psoriasis and you are having top surgery?
a. The patient and the surgeon should discuss and schedule the surgery for a time when the condition is least active or in remission.
b. Schedule the operation considering seasonal changes that affect psoriasis and its flare-ups.
c. Psoriasis sometimes affects the torso. Psoriatic plaques can form because of trauma to the skin, which includes surgical wounds. This may potentially influence the outcome after top surgery.
d. Psoriatic lesions at or around the site of operation should not affect the “flatness” achieved.
e. Psoriasis plaques may form on scars, which results in coloured and raised scars.
f. Minimise, and if possible, avoid, factors that may trigger psoriatic flare-ups (for example, stress/anxiety, alcohol consumption, smoking.
g. Look after the skin pre-operatively. For example, keep the affected skin moisturised, use topical treatments following the doctor’s advice, minimise binding and other factors that may increase sweating and skin stretching.
h. If sunlight exposure helps improve the presence and severity of psoriasis plaques on the skin during hotter months, you can follow the usual practice, always taking the necessary precautions when there is sun exposure, such as wearing sunscreen.
3. How can having surgery affect psoriasis?
a. Top surgery is a major operation, and it might affect someone’s immune system. This is because after any surgery, the body is using most of its resources to heal. If surgery affects the immune system, this in turn may trigger a flare-up of psoriasis.
b. Psoriasis or a flare-up should not affect “flatness.” However, psoriasis plaques may form on scars, which results in coloured and raised scars.
4. How to care psoriatic lesions and flare-ups after top surgery?
a. Topical care after surgery, with massaging the scars using a gentle moisturiser.
b. If sunlight exposure helps improve the presence and severity of psoriasis plaques on the skin during hotter months, you can follow the usual practice, always taking the necessary precautions when there is sun exposure, such as wearing sunscreen and protecting the new scar line from direct sunlight.
c. Use of scar care products should be outside the acute phase of psoriasis.
d. A balanced diet and a stress-free environment could also help healing and psoriasis flare-ups.
e. Hydration and looking after someone’s self are important.
5. Communication and follow-ups
a. There is not a rigid period for follow-ups. Watch and adjust is the most reasonable and wanted approach to care for a patient who has psoriasis and had top surgery. The aim is to support and reassure the patient.
b. If psoriasis appears after top surgery or if there is a psoriasis flare-up after top surgery, it will help if the patient discusses and considers a suitable management plan with their surgeon and GP/dermatologist both before and after surgery.
c. Caring for psoriasis and the skin lesions with medications (topical or systemic) should follow the doctor’s advice for safer results.
d. Open and adequate communication of the patient and the surgeon is necessary and helps the patient to receive the care they need and want.