Dr Sonali Kohli, Senior Consultant, Dermatologist, Sir HN Reliance Foundation Hospital explains how utilising genetic predisposition allows to modify disease course through evidence-based, directed interventions
Dr Sonali Kohli, Senior Consultant, Dermatologist, Sir HN Reliance Foundation Hospital
Psoriasis occurs in about 2-3 per cent of the world’s inhabitants as a chronic inflammatory cutaneous disorder with profound impacts on quality of life in involved patients. As clinicians, we more and more understand that family history is one of the strongest predictive factors for the identification of persons at risk. The issue of whether an early diagnosis in predisposed patients is able to radically change the course of the disease is a challenge for dermato- and functional therapeutic practice.
Psoriasis is highly heritable, with monozygotic twins concordance of 35-73 per cent, dizygotic twins concordance of 12-20 per cent.
From the functional medicine perspective, genetic predisposition is the “loaded gun,” and environmental stimuli pull the trigger. This paradigm gives us an opportunity to reverse modifiable risk factors even before the clinical manifestation.
Classic diagnostic testing is based on the traditional morphology of plaque, but early intervention calls for more sensitive tests. In individuals with a positive family history, we should have complete screening regimens with:
Nail psoriasis is seen in as many as 90 per cent of patients and usually arises before cutaneous lesions. Mild changes such as nail pitting, oil-drop colour change, and onycholysis may be early diagnostic signs in asymptomatic relatives.
The sooner the diagnosis, the greater the unprecedented potential for disease modification instead of symptom control. Pre-lesional anti-inflammatory therapies can avert the formation of chronic inflammatory cascades. They include maximised omega-3 fatty acid supplementation, curcumin therapies, and vitamin D optimisation—therapies that demonstrate quantifiable efficacy on inflammatory biomarkers.
New findings are revealing deep connections between intestinal permeability, dysbiosis of the microbiome, and psoriatic inflammation. Early treatment with specific probiotics, prebiotic fibre supplement intake, and withdrawal of gut irritants can end the “leaky gut-skin axis” activation that typically triggers psoriatic flares.
Preventive mitigation of stress with mindfulness-based therapy, cognitive behaviour therapy, and adaptogenic supplementation can greatly dampen cortisol-mediated inflammatory reactions in susceptible individuals.
Periodic assessments such as inflammatory markers, whole skin examination, nail examination, and review of lifestyle factors.
Evidence-based supplementation such as vitamin D (keeping them at >40 ng/mL), omega-3 fatty acids (2-4g per day), and probiotics tailored to the microbiome test.
Systematic detection and elimination of personal triggers such as dietary antigens, environmental toxins, and occupational hazards.
Achievement in early intervention is associated with outcome measures different from traditional PASI scores. Delayed onset of the disease, reduced initial severity, increased response to first-line therapy, and fewer frequency of flare episodes are a few clinically meaningful endpoints. Our longitudinal data show that patients who receive comprehensive early intervention demonstrate a 40-60 per cent reduction in initial disease severity compared to historical controls.
Obstacles to implementation include limitations on insurance coverage of preventive care, adherence of patients to extended protocols, and the necessity for more advanced biomarker panels. The emerging specialty of precision dermatology, with inclusion of pharmacogenomic testing and tailored therapeutic protocols, portends a previously unimagined ability to deliver truly personalised care.
Early diagnosis in a psoriatic pedigree is a paradigm shift from cure to prevention. Utilising genetic predisposition as potential, not destiny, allows us to genuinely modify disease course through evidence-based, directed interventions. This requires the marriage of traditional dermatologic knowledge with ideas of functional medicine, developing models of integrative care that address causal drivers, rather than symptom palliation.
The facts are unequivocal that early treatment and diagnosis can reduce and manage psoriatic flares, giving hope for our patients for improved long-term prognosis and quality of life.