Treatment For Psoriasis

Although there is no current cure for psoriasis, there is effective therapy that can control the condition by either reducing or clearing the patches. In the majority of cases, the patient can be treated by a GP (general practitioner, primary care physician).

If symptoms are severe, or if the patient has not responded well to treatment, the GP may refer them to a dermatologist (specialist skin doctor).

The aim of psoriasis treatment is to:

• Halt the cycle that causes increased skin cell production, leading to a reduction of inflammation and plaque production.
• Remove scale and smooth the skin.

The type of treatment depends on three main factors:

• The type of psoriasis
• The severity of symptoms
• Which areas of skin are affected

Most doctors will start with mild treatment, such as topical creams, see how the patient responds, and gradually introduce stronger treatments if necessary.

There are many treatment options. However, it is not always easy find the right one straight away. Patients should tell their doctor straight away if a treatment does not seem to be working, or if there are unpleasant side effects.

There are three main types of treatments, which are often used in combination:

• Topical - medications that are applied to the skin and are intended to affect only a specific area of skin. Examples include creams and ointments.
• Phototherapy - the skin is exposed to specific types of light.
• Oral or injected medications - used mainly to reduce skin cell production.

Topical treatments - usually used for mild to moderate psoriasis treatment.

• Topical corticosteroids - the most commonly used medication for mild to moderate psoriasis treatment. This type of medication helps slow down the production of skin cells, resulting in less inflammation and itching.
  Stronger corticosteroids may be used when small areas of skin are targeted.
  >It is important to follow the doctor’s instructions when using corticosteroids. Overuse can cause complications.
• Vitamin D analogues - these medications contain a synthetic form of vitamin D. They have a suppressing effect on the immune system and slow down the growth of skin cells. Calcipotriene or calclipotriol (Dovonex) is a prescription cream, ointment or solution, and is the most widely used vitamin D analogue for mild to moderate psoriasis. It may also be used in combination with other topical medications and/or phototherapy.
  According to The National Health Service (NHS), UK, calcipotriol has no side effects, as long as the patient does not use more than the amount recommended by the doctor.
• Anthralin (USA), Dithranol (UK) - very effective in suppressing skin cell production. It is believed to normalize DNA activity in skin cells. It can also remove scales, making the skin smoother. It is sometimes used in combination with phototherapy (ultraviolet light).
  According to The National Health Service (NHS), UK, it has no side effects.
  It is just for short-term treatment, typically under hospital supervision because it stains virtually anything it touches, including skin, clothing, bedding and worktops.
• Topical retinoids (tazarotene) - commonly used to treat acne and skin damaged by overexposure to sunlight. However, tazarotene (Tazorac, Avage) was developed just for psoriasis treatment. This cream contains a chemical similar to vitamin A; it normalizes DNA activity in skin cells, slowing down skin cell production and often reducing inflammation. It is used to treat moderate plaque psoriasis.
  A common side effect is skin irritation. Some people find it increases their skin’s sensitivity to sunlight, so often a sunscreen is recommended.
  Topical retinoids have a much lower risk of birth defects than oral retinoids. However, if the patient is pregnant or intends to become pregnant it is important that the doctor be told. Topical retinoids are usually avoided if a woman is pregnant or breastfeeding.
• Coal tar - this is probably the oldest treatment for psoriasis. Coal tar is a thick, black, heavy oil byproduct of the manufacture of petroleum products. It reduces scaling, itching and inflammation. Nobody is sure how it works. Although it has few known side effects, it is messy, has a strong smell, and can stain clothing and bedding. Coal tar can be bought OTC (over-the-counter, no prescription required) at pharmacies and other stores/supermarkets as shampoos, oils and creams.
  Coal tar is frequently used in combination with phototherapy.
• Moisturizers - on their own, moisturizing creams will not heal the condition. However, they can help with itching and scaling, as well as reducing the dryness that sometimes occur with other therapies. Ointments containing a moisturizer are usually better than lighter lotions or creams.
• Salicylic acid (also chemically known as orthohydroxybenzoic acid) - obtained from plants (white willow back and wintergreen leaves). Patients with psoriasis can use it as a peeling agent in ointments, creams, gels and shampoos. Products can be bought over-the-counter. It is also the active ingredient in many products for the treatment of acne. Salicylic acid causes skin cells to slough off more easily, preventing them from blocking up the pores. It also reduces scaling.

Phototherapy - this means treatment with light, which can be either artificial or natural.

• Sunlight - exposing the skin to limited amounts of direct sunlight can alleviate symptoms. However, too much sunlight may cause skin damage and worsen symptoms.
  UV (ultraviolet) light is a light wavelength that is too short for our eyes to see. When our skin is exposed to UV rays the activated T cells in the skin die, resulting in a more normal skin cell turnover, as well as less scaling and inflammation.
  Patients should embark on sunlight treatment only under the supervision and advice of their doctor.
• UVB (ultraviolet B) phototherapy - treatment takes place at a hospital under the supervision of a dermatologist. This therapy can slow down the production of skin cells. It is effective for the treatment of guttate or plaque psoriasis, especially if the patient has not responded to topical treatments.
  The patient receives controlled doses of UVB light from an artificial source.
  In the short-term there may be redness, itching and dry skin in the treated area. A moisturizer may help minimize these side effects.
• PUVA (psoralean plus ultraviolet A) - the patient is first given a psoralean tablet, a light-sensitizing medication (it makes the skin more sensitive to light). The skin is then exposed to controlled doses of ultraviolet A (a type of light). Ultraviolet A penetrates more deeply into the skin, compared to UVB light.
  PUVA treatment is typically used if the patient has severe symptoms, which have not responded to other treatments.
  
  Side effects may include:
  • Headaches
  • Nausea
  • Itching
  • Burning
  Long-term use of PUVA treatment may increase the risk of skin cancer. Typically, treatment involves two to three sessions per weeks for a prescribed number of weeks.

Combination light therapy - the effectiveness of phototherapy is often enhanced if other treatments are given at the same time. Combination light therapy is typically used when phototherapy on its own has not been effective. Examples include phototherapy combined with:

• Coal tar therapy (Goeckerman treatment) - coal tar makes the skin more receptive to the phototherapy.
• Anthralin (UK: Dithranol) therapy.
• Ingram regimen - a combination of UVB therapy with a coal tar bath and an anthralin-salicylic acid paste that remains on the patient’s skin either overnight or for several hours.

Oral and injected medication - doctors may prescribe oral tablets or injections if symptoms are severe and other treatments have not been effective. Although oral medications are very effective, they have potentially serious side effects. Therefore, treatment courses need to be short.

According to The National Health Service, UK, all oral and injected medications for the treatment of psoriasis have both benefits and risks. It is important that the doctor explains both the benefits and risks, both verbally and in writing, before treatment begins.

• Methotrexate - this medication is an antimetabolite. It is a folic acid antagonist that slows down the synthesis of DNA, RNA and protein. It is used to treat diseases in which cell growth is excessive, such as psoriasis and some tumors. It is also helpful in treating autoimmune diseases, such as dermatomyositis and rheumatoid arthritis.
  As far as psoriasis patients are concerned, methotrexate decreases the production of skin cells and suppresses inflammation. It is especially useful in the treatment of pustular psoriasis, psoriatic erythoderma, and extensive plaque psoriasis.
  
  In the short-term and in lower doses it is not known to have side effects. However, in higher doses, or in the long term, it can cause serious liver damage.
  
  The most common reactions (undesirable side effects) are:
  • Possible liver damage
  • Mouth sores
  • Stomach upset
  • Low white blood count
  The following characteristics of methotrexate should also be borne in mind:
  • Patients with any history of liver disease should not be given methotrexate
  • Women should be especially careful not to get pregnant while taking methotrexate (and for three months after stopping treatment), because it can cause serious birth defects.
  • Males should not attempt to get a partner pregnant with their sperm during treatment, and for three weeks after stopping treatment. Methotrexate may affect the development of sperm cells.
• Acitretin (Soriatane) - this is an oral retinoid, which is a synthetic form of vitamin A. In the USA Soriatane is the only oral retinoid approved by the Food and Drug Administration (FDA) specifically for the treatment of psoriasis.
  Acitretin helps control the multiplication of cells (reduces the rate at which skin cells are produced). It is used to treat severe psoriasis that has not responded to other treatments.
  
  Acitretin should NOT be taken if:
  • The patient is pregnant or planning to become pregnant. Because of the risk of serious birth defects, women of childbearing potential usually have to have two negative pregnancy tests before starting treatment with this drug. Women should also use two effective forms of birth control for at least one month before treatment begins, and for three years after treatment is over. While taking acitretin, progestin-only birth control pills should not be used as a primary form of birth control, because they may not work.
  • The patient is breastfeeding.
  • The patient has severe liver or kidney disease
  • The patient has high triglycerides.
  • The patient is allergic to retinoids.
  During treatment and for three years after it is over, the patient should not donate blood; because it could expose pregnant women to acitretin.
  The following side effects are possible:
  • Dryness and cracking of lips
  • Dryness in the nasal passages
  • Hair loss
  • Hepatitis (rare)
• Ciclosporine (ciclosporin) - this is an immunosuppressant medication (it reduces the immune system) that is commonly prescribed to organ transplant patients to prevent rejection. It is also used in psoriasis, severe atopic dermatitis, pyoderma gangrenosum, chronic autoimmune urticaria, and, infrequently, in rheumatoid arthritis and related diseases.
  
  Ciclosporin has been shown to be effective for all types of psoriasis. It is similar to methotrexate in effectiveness. As it reduces the patient’s immune system, patient may have a higher risk of infection, as well as cancer.
  
  The risk of kidney disease and hypertension (high blood pressure) is also higher when taking this medication - the risk grows if dosages are higher, or therapy is longer lasting.
• Biologic treatments - biologics or biological products are made from living organisms; from living animal or human proteins. Biologics have recently emerged as a new treatment for patients with severe psoriasis symptoms. They work by targeting the immune system - they target the overactive cells in the body that play a role in psoriasis.
  
  According to the National Health Service, biologic treatments are very expensive; so they are only recommended for patients with severe psoriasis symptoms who have not responded adequately to other treatments.
  Examples of biologic treatments (immunodilator drugs) for psoriasis include:
  • Enbrel (etanercept)
  • Amevive (alefacept)
  • Remicade (infliximab)
  • Stelara (ustekinumab)
  These drugs are given by:
  • Intravenous infusion - injecting into the vein.
  • Intramuscular injection - injecting into muscle.
  • Subcutaneous injection - injecting just under the skin.
  Biologics block interactions between certain immune system cells. Even though they are derived from natural sources, as opposed to chemical ones, they may have strong side effects on the immune system and should be used with caution.