Psoriasis

Plaque psoriasis

• Emollients http://www.dynamed.com/condition/psoriasis#SKIN_CARE may be used either simultaneously with other treatments or as follow-up treatment. In very mild cases they may suffice as the sole treatment form.
• Topical preparations of vitamin D (calcitriol) and its derivatives (calcipotriol that may require a special license) http://www.dynamed.com/condition/psoriasis#VITDANAL are efficient and safe in long-term management of plaque psoriasis Corticosteroids and Vitamin D Analogues for Chronic Plaque Psoriasis. Local skin reactions may occur. The use of topical vitamin D may be hampered by the need to apply the preparation regularly twice daily in order to achieve full efficacy and, moreover, treatment response will not be evident until after 4-6 weeks. This is the safest and most recommended treatment form, but only a few patients are able to continue long-term with the regular applications.
• Topical glucsocorticoidhttp://www.dynamed.com/condition/psoriasis#TOPSTEROIDS (potent to very potent, i.e. group III-IV) have a rapid onset of action and will also alleviate itchiness, which is present in about 70% of patients. They should initially be used continuously for 2-4 weeks followed by gradual dose reduction and cessation. Abrupt cessation should be avoided as it will lead to early recurrence. An attempt must be made to avoid the emergence of known adverse effects of long-term use and the patient must be appropriately monitored.
• The combination product of calcipotriol and betamethasone dipropionate http://www.dynamed.com/condition/psoriasis#TOPIC_ND5_2JM_J4B is the fasted and most effective topical treatment for plaque psoriasis Corticosteroids and Vitamin D Analogues for Chronic Plaque Psoriasis. Foam is the most effective preparation type. Once daily application is sufficient. The initial treatment period lasts for 4 weeks and should be followed by one of the following studied maintenance regimes:
  • calcipotriol orcalcitriol once or twice daily long-term
  • the combination product on weekends or
  • the combination product when required.
  • Occlusive dressings used alone with no added medication have been reported to be effective in localised plaque psoriasis. They may enhance the efficacy of glucocorticoid preparations, particularly when treating isolated persistent plaques.
    • In a 52-week study, 4.8% of users developed glucocorticoid-induced adverse effects.

Plaque psoriasis in specific areas

• Scalp psoriasis (pictures 38 39) is treated with frequent shampooing (periodically, using an anti-dandruff shampoo). If necessary, salicylic acid exfoliation may be used initially followed by a glucocorticoid solution or a combined preparation.
  • A layer of scales will prevent the penetration of medicated preparations.
  • Salicylic acid is often used as a 5-10% mixture (prepared in the pharmacy) in a cream, castor oil or macrogol ointment base.
• Psoriasis on the face may be treated by
  • moderately potent glucocorticoid preparations
  • pimecrolimus and tacrolimus (check reimbursement status) http://www.dynamed.com/condition/psoriasis#CALCINEURIN
• Flexural psoriasis may be managed with the same preparations as those used on the face. Some patients may also tolerate vitamin D (calcitriol) ointment in flexural areas.
• The treatment of psoriasis on the palms and the soles of the feet (pictures 40 34 41) consists of the above mentioned medicines used in plaque psoriasis. To treat hyperkeratosis, salicylic acid may be mixed up to 20% potency. In the most severe cases, a systemic drug (acitretin, methotrexate) is needed.

Guttate psoriasis

• If guttate psoriasis is not very extensive, the topical treatment forms described for plaque psoriasis may be used, particularly topical glucocorticoids.
  • UVB phototherapy is the treatment of choice for extensive guttate psoriasis.

Pustular psoriasis and erythrodermic psoriasis

• The principal treatment regime consists of systemic drugs, which may be supplemented with emollients and topical glucocorticoids.

Phototherapy Phototherapy for Psoriasis

• Phototherapy http://www.dynamed.com/condition/psoriasis#PHOTOTHERAPY may be used in extensive guttate and plaque psoriasis in persons whose skin tolerates exposure to the sun and tans easily.
• Certain photosensitising medications may be a contraindication for phototherapy.
• Spending time in natural sunlight will alleviate psoriasis.
  • To achieve a good treatment response, the daily exposure to sunlight must continue for 3 weeks.
  • Adjustment training courses with emphasis on heliotherapy may be covered by national health insurance schemes. The insurance cover varies from country to country. Lost earnings may also be reimbursable.
• Ultraviolet B radiation (UVB treatment). The prescribing physician must be familiar with the patient's particular skin type as well as the radiation spectrum and dose rate emitted by the phototherapy equipment. Moreover, the amount of radiation exposure and the cumulative dose must be recorded. If the treatment has benefited the patient, a general practitioner may prescribe repeat sessions.
  • The conventional broadband UVB therapy is effective in guttate psoriasis and in mild plaque psoriasis. The therapy is not associated with an increased cancer risk.
    • It may be possible to install a phototherapy unit at the patient's home. Home UVB phototherapy is a very cost-effective treatment modality.
  • Narrowband UVB therapy (311-313 nm) is more effective than broadband therapy and is the phototherapy of choice in psoriasis.
    • The treatment efficacy is as good as, or better than, that achieved with bath-PUVA (using topical psoralens).
    • So far there is inadequate data as regards the risks of long-term use.
• In PUVA therapy (combining a psoralen and ultraviolet A) Systemic Treatments for Severe Psoriasis, the patient's skin is sensitised to light with a psoralen, which is administered either topically (bath-PUVA or cream-PUVA) or by mouth (oral-PUVA). PUVA therapies are nowadays only rarely used and they may be prescribed by a specialist physician only.

Systemic drug therapy

• Acitretinhttp://www.dynamed.com/condition/psoriasis#ACITRETIN, methotrexateMethotrexate for Psoriasishttp://www.dynamed.com/condition/psoriasis#METHOTREXATE and ciclosporin Cyclosporin for Psoriasis http://www.dynamed.com/condition/psoriasis#CYCLOSPORINE are the primary drugs for systemic treatment of psoriasis. Of these, methotrexate is best suited for long-term treatment. When used for a long time it reduces the increased cardiovascular risk of the patients.
• Secondary systemic drugs for the treatment of severe psoriasis are the oral apremilast and dimethyl fumarate as well as the parenterally administered biological drugs.
  • Reimbursement policies may vary from country to country.
  • The efficacy of apremilast and dimethyl fumarate is comparable to that of methotrexate.
  • Apremilast is licensed also for psoriatic arthritis.
• Biologicals http://www.dynamed.com/condition/psoriasis#BIOLOGIC_AGENTS may be considered for the treatment of severe psoriasis.
  • Adalimumab, etanercept, ixekizumab, infliximab, secukinumab, certolizumabpegol and ustekinumab are licensed for the treatment of both skin psoriasis and psoriatic arthritis, brodalumab, guselkumab, risankizumab and tildrakizumab for skin psoriasis only (the licensing may vary from country to country).

Referral to specialist

• Children affected by psoriasis (pictures 10 1) and patients with psoriasis not responding to usual treatment modalities
• A young person with recently developed psoriasis that affects the skin extensively or in visible areas of the skin.
• Suspicion of excessive glucocorticoid use (pictures 42 43)
• An experienced dermatologist can be more helpful in the diagnosis of problematic psoriasis than sending off a skin biopsy.