Treatment of Psoriasis

Topical treatments: localized treatment with drugs such as steroid, retinoid, vitamin D, moisturizing agent (e.g. Vaseline).

Conventional systemic therapies: localized treatment with drugs such as steroid, retinoic acid, vitamin D, moisturizing agent (e.g. Vaseline).

Phototherapy: Exposure to long-wave ultraviolet light A (UVA) or short-wave ultraviolet light B (UVB). The advantage is that it produces less systemic side-effect with long-term use. However it is more time consuming, and may cause skin pigmentation, aging, and skin cancer.

Biologic drugs: there are currently two types of biologic drugs, one blocks the action of tumor necrosis factor-alpha (TNF-alpha) and the other blocks interleukins 12 and 23. Blocking TNF-alpha helps treat psoriasis and psoriatic arthritis.

Topical steroids

Topical treatment is still the most simple and convenient treatment option available. It is suitable for patients with small area or minimal lesions. It is also the optimal treatment method for those who have to work or go to school, or those who are unable to receive regular UV ray therapy. Around 80% of psoriasis patients are receiving topical treatments. They may be used in conjunction with oral medication, phototherapy or biologic drugs. Topical drugs control inflammatory response, promote vasoconstriction, and slow skin cell growth. Clinically, they provide rapid relief to redness of lesions, reduce the swelling of patches, and alleviate scaling and itching. The effects are immediate and noticeable.

Ointment or cream: light and non-greasy texture.

Ointment: More moisturizing than cream, suitable for lesions with severe dryness and scale.

Lotion, solution, and foam : Suitable for lesions covered by hair or large affected area. These forms of applications are well absorbed, spread easily, and do not leave hair sticky.

Shampoo: Shampoo hair as usual to cover the entire affected area.

Long-term use of topical steroids can lead to side-effects, such as folliculitis, excessive hair growth, rosacea, milia, subcutaneous hemorrhage, and poor healing of wounds. Using on widespread lesions may induce systemic side-effects hence they must be used with caution. Although topical steroids produce immediate results, patients must always follow medical instructions. Never adjust the dosage or overuse potent steroid cream without proper instruction to avoid adverse reactions or side-effects.

Oral treatment

Treatments for mild to moderate psoriasis begin with topical application and phototherapy. Moderate to severe psoriasis require topical treatment as well as systemic oral medication to regulate and inhibit immune response. Oral medications include retinoid (neotigason), methotrexate, cyclosporin, azathioprine (imuran), and hydroxyurea.

Methotrexate--

Inhibits active lymphocytes, anti-inflammatory.

A low dose regimen (7.5~25 mg) once weekly achieves effective outcome

Common side-effects include gastrointestinal discomfort, skin ulcer, and angular cheilitis.

Individuals taking methotrexate must have regular blood tests to assess blood count and liver function. Methotrexate may suppress blood cell production by the bone marrow in some patients. It may also cause hepatotoxicity in patients with hepatitis B or C, or with alcoholic liver disease.

Methotrexate is capable of causing fetal malformations hence is prohibited for pregnant females. Men should be off methotrexate at least three months before trying to conceive. Women should wait at least one ovulatory cycle after therapy to become pregnant.

Oral retinoids

The selected medication for pustular psoriasis and erythrodermic psoriasis.

Combining oral retinoids with phototherapy produces additional effect in treating chronic plaque psoriasis.

Monitoring of liver function and serum lipids is essential during treatment.

Retinoids should not be used by pregnant women due to their potential for causing abnormalities in an unborn child. Women should wait at least three years after therapy to become pregnant.

Cyclosporin

It is an effective short-term treatment for severe psoriasis flare ups.

Must monitor for abnormal renal function and hypertension.

Oral medications generally product treatment effect after 4-6 weeks. Their potential side-effects include impaired liver or renal function and abnormal serum lipids. Therefore, patients are advised to adhere to the treatment regimen, attend follow-ups, and undergo regular blood tests. In most cases, psoriasis is a lifelong condition that can be properly managed when the patients are able to receive routine treatment and avoid triggers (e.g. stress, smoking, alcohol, infection, injuries, and drugs) that aggravate the disease.

Phototherapy

Phototherapy for psoriasis is available in many forms, including long wavelength, short wavelength with narrow band, and short wavelength with broad band. The advantages of these various types of phototherapy are that they do not affect organ functions, there is no drug interaction, and they produce longer treatment effects. For psoriasis patients with other chronic conditions and need to take medications daily for these diseases, phototherapy can be a suitable option for the doctors and patients.

The most frequent side-effect of phototherapy is sunburn. Sometimes younger female patients dislike or are even troubled by the skin tanning from therapy. Treatment regimens can be complex and time-consuming and require frequent trips to the hospital. These are the primary contributors to patient dislike and non-compliance of the treatment. However, phototherapy can be an effective means of symptom control for retired elderly adult or younger school age patients.

To develop a personalized treatment plan for patients with moderate or severe psoriasis, dermatologist must consider the potential efficacy and clinical safety of the therapy. Comparing with other psoriasis treatment, phototherapy offers excellent efficacy and is relatively safe. It can be used independently or in conjunction with other topical application, oral medication or biologic drugs. For patients who have tried other treatment methods but unsatisfied with the treatment outcome or have doubts regarding treatment safety, they may discuss with their dermatologist and explore phototherapy as a possible option. During the regimens, patients must have patience in communicating and cooperating with the health professionals to maximize treatment benefit, as phototherapy is a complex and specialized medical practice.

Biologics

The conventional topical applications and oral medications for psoriasis are produced from chemical compounds. Biologics contain ingredients sourced from living organisms including human, animals, plants, and micro-organism. A common ingredient is insulin. The new generation of biologics are produced through recombinant DNA technology. Newly developed biologics are primarily for treating cancer and autoimmune diseases including psoriasis.

Directions

There are currently three biologics for psoriasis which are all administered as subcutaneous injections. After the first injection, treatment with Enbrel consists of twice weekly injection, Humira consists of once every other week, and Stelara consists of once every three months.

The advantages and disadvantages of biologic treatment.

The literature indicates satisfactory efficacy for the t types of biologics mentioned above. After three to six months of treatment, more than 60% of the patients demonstrate more than 75% recovery.

Advantages: They offer more convenient dosing regimens. Patients do not have to spend time on applying topical treatment and endure the greasiness of these drugs. Unlike the conventional oral immune regulatory drugs, regular blood examinations and liver function monitoring are not necessary. Biologics have also demonstrated improved efficacy, longer remission period, increased quality of life, enhanced treatment compliance and intension, and indirect prevention of metabolic syndrome.

Disadvantages: Biologic therapies for psoriasis are associated with increased risk of infection, with tuberculosis being the most commonly reported infection. Therefore, patients using biologics are advised to receive chest x-rays and blood examinations (IGRA) to monitor for and reduce the risk of tuberculosis infections.