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* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is very detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.

Psoriasis


WHAT IS PSORIASIS?



General Definition of Psoriasis


Psoriasis is a chronic skin disease marked by periodic flare-ups of sharply defined red patches covered by a silvery, flaky surface. The primary activity leading to psoriasis occurs in the epidermis, the top five layers of the skin.
  • The process starts in the basal (bottom) layer, where keratinocytes (immature skin cells) are produced. These cells, in turn, manufacture keratin, a tough protein that helps form hair and nails as well as skin.

  • In normal cell growth, keratinocytes mature and migrate from the bottom (basal) layer to the surface and are shed unobtrusively. This process takes about a month.

  • In psoriasis, the keratinocytes proliferate very rapidly and travel from the basal layer to the surface in only about four days.

  • The skin cannot shed these cells quickly enough so they accumulate in thick, dry patches, or plaques.

  • Silvery, flaky areas of dead skin are shed from the surface.

  • The underlying area is red and inflamed due to another important change that occurs in the dermis. This skin layer, located below the epidermis, contains nerves and blood and lymphatic vessels.

  • In psoriasis, these blood vessels provide an increased blood supply to the abnormally multiplying keratinocytes, causing the underlying inflammation and redness characteristic of psoriasis.
Increasingly, it is believed that these destructive changes originate from genetic abnormalities in the immune system that are triggered by environmental factors.

A number of psoriasis variants exist. Some can occur independently or at the same time as other variants, or one may follow another. The most common psoriasis variant is called plaque psoriasis. Psoriatic arthritis is an important disorder that includes both psoriasis and arthritis. [For other variants of psoriasis See Table Less Common Forms of Psoriasis.]


Plaque Psoriasis


Description of Plaque Psoriasis Patches. It is described as follows:
  • The patches start off in small areas, about one-eighth of an inch in diameter.

  • They gradually enlarge and develop thick, dry plaque. If the plaque is scratched or scraped, bleeding spots the size of pinheads appear underneath (known as the Auspitz sign ).

  • Some patches may become ring shaped (annular) with a clear center and scaly raised borders that may be wavy and snake-like.

  • Patches usually appear symmetrically, that is, in the same areas on opposite sides of the body.

  • Eventually separate patches may join together to form larger areas as the disorder develops. In some cases, the patches can become very large and cover wide areas of the back or chest (known as geographic plaques because they resemble maps).
Plaque psoriasis develops in the following locations:

Location of Plaque Psoriasis. They most often occur on the elbows, knees, and the lower back.
  • Patches also can appear on the palms and soles, in the genital areas of both men and women, above the pelvic bone, and on the thighs and calves of the legs.

  • Although psoriasis rarely affects the face in adults, about half of patients develop psoriasis in the scalp. Many patients have only a few patches in this location. In some cases, however, psoriasis can cover the scalp with thick plaques that may even extend down from the hairline to the forehead.

  • In children, psoriasis is most likely to start in the scalp and spread to other parts of the body; unlike in adults, it also may occur on the face and ears.
Course of Plaque Psoriasis. Plaque psoriasis may persist for long periods. More often it flares up periodically, triggered by certain factors, such as cold weather, infection, or stress.


Psoriatic Arthritis


Psoriatic arthritis (PsA) is an inflammatory condition that is associated with psoriasis. It is not clear whether psoriatic arthritis is unique or is a genuine variation of psoriasis. (Some evidence suggests, however, that both psoriatic arthritis and psoriasis are caused by the same autoimmune process.)

Description of Psoriatic Arthritis. Psoriatic arthritis is characterized by stiff, tender, and inflamed joints. Arthritic and skin flare-ups tend to occur at the same time.

Location of Psoriatic Arthritis.
  • Psoriatic arthritis usually affects less than five joints, often causing deformities in the fingers and toes. About 80% of PsA patients have psoriasis in the nails.

  • It can occur in the knees, hips, elbows, and spine. When it affects the spine, psoriatic arthritis most frequently targets the sacrum (the lowest part of the spine). Although estimates of spine involvement have ranged between 30% and 50%, one study suggests that the sacrum may be affected in more than three-quarters of patients with psoriatic arthritis.
Course of Psoriatic Arthritis. Although patients with psoriatic arthritis tend to have mild skin manifestations, the disease is systemic; that is, it affects the body as a whole. PsA, therefore, is more serious than the common psoriatic condition.

Infrequently, the course of PsA has been associated with a syndrome known by the acronym SAPHO, whose letters form the symptoms:
  • Synovitis (inflammation in the joints).

  • Acne.

  • Pustule eruptions.

  • Hyperostosis (abnormal bony growths).

  • Osteolysis (bone destruction).
Prevalence of Psoriatic Arthritis . Estimates on its prevalence among psoriasis patients range from 2% to as high as 42%. Patients at highest risk are those with severe conditions or who have AIDS.


Less Common Forms of Psoriasis


Psoriasis Form Description Other Factors
Guttate Psoriasis
  • The patches are teardrop-shaped that erupt suddenly, usually over the trunk and often on the arms, legs, or scalp.

  • The teardrop patches often resolve on their own without treatment.
Guttate psoriasis can occur as the initial case of psoriasis. Usually this event affects children and young adults, often about one to three weeks after a viral or bacterial (usually streptococcal) infection in the lungs or throat. A family history of psoriasis and stressful life events are also highly linked with the onset of guttate psoriasis.

Guttate psoriasis can also develop in patients who have had earlier forms of psoriasis. In such cases, it is more likely to emerge in people treated with widespread topical corticosteroid dressings.
Inverse Psoriasis
  • Patches usually appear as smooth inflamed patches without a scaly surface.

  • They occur in the folds of the skin, such as under the armpits or breast or in the groin.
Seborrheic Psoriasis Seborrheic psoriasis appears as red scaly areas in the scalp, behind the ears, above the shoulder blades, in the armpits, the groin, and in the center of the face.
Nail Psoriasis
  • • The characteristic signs are tiny white pits scattered in groups across the nail.

  • Long ridges may also develop across and down the nail.

  • Toenails and sometimes fingernails may have yellowish spots.

  • The nail bed often separates from the skin of the finger and collections of dead skin can accumulate underneath the nail.
Over half of patients with psoriasis have abnormal changes in their nails.

Such nail changes may appear before psoriatic skin eruptions occur.

In some cases, nail psoriasis is the only type of psoriasis.
Generalized Erythrodermic Psoriasis. (also called psoriatic exfoliative erythroderm In rare severe cases, psoriasis develops into generalized erythrodermic psoriasis
  • The skin surface becomes scaly and red.

  • The disease covers all or nearly all of the body.
About 20% of such cases evolve from psoriasis itself. It can also be caused by certain psoriasis treatments.

This condition can also erupt after withdrawal from other agents, including corticosteroids or synthetic antimalarial drugs.


Pustular Psoriasis


  • Psoriasis patches become pus-filled and blister-like.

  • The blisters eventually turn brown and form a scaly crust or peel off.

  • Pustules usually appear on the hands and feet. (When they form on the palms and soles, the condition is called palmar-plantar pustulosis.)
The condition may erupt as the first occurrence of psoriasis or may evolve from plaque psoriasis. It can also accompany other forms of psoriasis. If pustular psoriasis occurs with generalized erythrodermic psoriasis and becomes widespread, it becomes very dangerous and is referred to as Von Zumbusch psoriasis.

A number of conditions may trigger pustular, including the following:
  • Infection

  • Pregnancy

  • Certain drugs

  • Metal allergies



WHAT IS THE CAUSE OF PSORIASIS?


The precise causes of psoriasis are unknown. It is generally believed that psoriasis is a disorder in which factors in the immune system, enzymes, and other biochemical substances that regulate skin cell division become impaired causing rapid keratinocyte (immature skin cell) proliferation and inflammation. Such abnormalities are likely due to one or more genetic defects. The process also probably needs an environmental trigger, such as weather or stress, to set it off.


Inflammatory Response and Autoimmunity


The Normal Immune System Response. The inflammatory process is a byproduct of the body's immune system, which fights infection and heals wounds and injuries:
  • When an injury or an infection occurs, white blood cells are mobilized to rid the body of any foreign proteins, such as a virus.

  • The masses of blood cells that gather at the injured or infected site produce factors to repair wounds, clot the blood, and fight any infective agents.

  • In the process, the surrounding area becomes inflamed and some healthy tissue is injured.

  • Under normal conditions, the immune system has other factors that control and limit this inflammatory process.
The Infection Fighters. The primary infection-fighting units are two types of white blood cells: lymphocytes and leukocytes.

Lymphocytes include two subtypes known as T-cell s and B-cells. Both types of cells are designed to recognize foreign invaders (antigens) and to launch an offensive or defensive action against them:
  • B-cells produce antibodies, which are separate agents that can either ride along with a B-cell or travel on their own to attack the antigen.

  • T-cells have special receptors attached to their surface that recognize the specific antigen.
T-cells are further categorized as killer T-cells or helper T-cells (TH cells).
  • Killer T-cells directly attack antigens that occur in any cells that contain a nucleus.

  • Helper T-cells also recognize antigens, but their role is two fold. They stimulate B-cells and other white cells to attack the antigen. They also produce cytokines, powerful immune factors that have an important role in the inflammatory process .
Helper T-Cells, Cytokines, and the Inflammatory Response. The actions of the helper T-cells (TH-cells) are of special interest. Researchers have observed high numbers of these T-cells in psoriatic plaques:
  • The activated helper T-cells (TH cells) infiltrate the skin cells in psoriasis, and in the case of psoriatic arthritis, the joints. (There has been some debate over whether psoriatic arthritis is a unique disorder, but evidence now suggests that both psoriatic arthritis and psoriasis are caused by the same autoimmune process.)

  • TH-cells normally stimulate B-cells to produce antibodies. In the case of psoriasis, however, they appear to direct the B-cells to produce autoantibodies, which are directed against the body's own cells.

  • Autoantibodies are primary factors in the autoimmune process. They are designed to target specific cells in the persons own body (self, antigens ). They also remain in circulation to continue the defense against them. In the case of psoriasis, these are cells in the skin.
Helper-T-Cells and Cytokines. TH-cells also secrete or stimulate the production of powerful immune factors called cytokines. In small amounts, cytokines are indispensable for healing. If overproduced, however, they can cause serious damage, including inflammation and injury during the psoriasis process. In psoriasis, researchers are particularly interested in cytokines known as GRO-alpha, tumor necrosis factor, and interleukins 8 (IL-8), 11 (IL-11), and 12 (IL-12), which appear to play strong roles in the destructive psoriatic process, and in IL-10, which may be protective and block cell growth leading to psoriasis.

Neutrophils. Cytokines attract to the scene large numbers of other large white blood cells known as neutrophils. Neutrophils stimulate the production of arachidonic acid, which triggers about 30 different chemicals, including two key players in the inflammatory process:
  • Leukotrienes, which attract even more white blood cells to the area, and

  • Prostaglandins, which open blood vessels and increase blood flow.


Genetic Factors


A combination of more than one of these genes is involved with increasing a person's susceptibility to autoimmunity or other conditions leading to psoriasis.

HLA Molecules. The processes leading to all autoimmune disease involve the human leukocyte antigen (HLA) system, which is genetically regulated. Malfunction of this system is at the root of most immune disorders, including psoriatic arthritis. HLA molecules are designed to pick off parts of antigens and present them on the surface of a cell so that the factors in the immune system can recognize and destroy them.

Some disorders called spondyloarthropathies (inflammatory diseases in the spine), including psoriatic arthritis are highly associated in European and North Americans with a specific HLA genetic factor, HLA-B27. Patients with CW6 HLA genes tend to develop psoriasis at an earlier than average age.

PSORs. Researchers in the US, Canada, and Europe have now identified four key genes (named PSORs 1-4) that are involved with psoriasis. Of particular interest are the genes located in regions on specific chromosomes that are linked to HLA and tumor necrosis factor, an immune component strongly associated with psoriasis.


Environmental and Other Triggers


Outside factors, including weather, stress, injury, and infection, while not direct causes, are often important in triggering the disease process leading to onset and worsening of psoriasis.

Weather. Weather is a strong factor in psoriasis:
  • Cold, dry weather is a common precipitant of psoriasis flares.

  • Hot, damp, sunny weather helps relieve the problem in most patients.

  • To confuse matters, some people have photosensitive psoriasis, which actually improves in winter and worsens in summer when skin is exposed to sunlight.
Stress and Strong Emotions. Stress, unexpressed anger, and emotional disorders, including depression and anxiety, are strongly associated with psoriasis flares. In one study, nearly 40% of patients remembered a specific stressful event that occurred within a month of a psoriasis flare. Some studies have suggested that patients with psoriasis respond to stress differently than people without the skin disease. In one study, psoriasis patients had fewer aggressive verbal responses than others when confronted with circumstances designed to provoke anger.

Infection. Infections caused by viruses or bacteria can trigger some cases of psoriasis. Some examples include the following:
  • Streptococcal infections in the upper respiratory tract, such as tonsillitis, sinusitis, and so-called "strep" throat, are known to trigger psoriasis, particularly guttate psoriasis in people with a specific genetic type known as HLA-B13.

  • The human immunodeficiency virus (HIV) is also associated with psoriasis.
Although experts have sought a bacterial or viral agent as a cause of pustular psoriasis, none have been identified thus far.

Skin Injuries and the Köbner Response. The Köbner response is a delayed response at the site of previous injuries (eg, cuts, burns, injections, previous skin disorders), in which psoriasis then develops. In some cases, even mild abrasions can cause an eruption, which may be a factor in the frequency of psoriasis on the elbows or knees. (It should be noted that psoriasis can develop in areas with no history of skin disruption.)

Drugs. A number of drugs can worsen or induce pre-existing latent psoriasis, including the following:
  • The anti-malarial drug chloroquine.

  • Certain drugs used for hypertension and heart problems, including angiotensin-converting enzyme (ACE) inhibitors. Beta-blockers may actually trigger the onset of psoriasis and produce flares in people who already have it.

  • Progesterone.

  • Lithium, which is used in bipolar disorder. (It may trigger the onset of the disease and cause severe flares in people who already psoriasis.)

  • Indomethacin, a non-steroidal anti-inflammatory drug (NSAID), can cause or worsen psoriasis (although other NSAIDs, such as meclofenamate, may actually improve the condition).

  • Withdrawing from oral steroids or high-potency steroid ointments that cover wide skin areas can cause flare-ups of severe psoriasis, including guttate, pustular, and erythrodermic psoriasis. Because these drugs are also used to treat psoriasis, this rebound effect is of particular concern.

  • An agent that causes rashes can trigger psoriasis as part of the Köbner response.


WHO GETS PSORIASIS?



Age and Gender


An estimated 6.4 million Americans (about 2.6% of the population) have psoriasis, and it affects between 0.5% to 3% of the world's population.

Gender. Some studies have indicated a higher prevalence in men than in women.

Age. About 40% of patients report developing psoriasis before age 20 and 10% had the disease before age 10. Psoriasis (most often plaque psoriasis) can even occur in infants as well as children and adolescents, although mild or atypical symptoms can make it difficult to diagnose properly.


Family History


About 35% of those with psoriasis have one or more family members with the disorder. One study reported that the lifetime risk for psoriasis is 4% in someone with no afflicted family members, 28% with one affected parent, and 68% with both parents affected by psoriasis.


Geography and Ethnicity


Climate plays a role in risk. Some studies have found that the disorder develops earlier and more frequently in colder climates. For example, psoriasis occurs more frequently in African Americans and in Caucasians who live in colder climates than in people of any ethnicity who live in Africa. Psoriasis is also common in Japanese individuals. It is uncommon in Native Americans of either North or South American descent.


HOW SERIOUS IS PSORIASIS?



Course of Psoriasis


Psoriasis is lifelong and not curable. Although it is also marked by rapid cell growth, psoriasis is neither cancerous nor contagious. In general, studies report the following features of its course:
  • The condition almost always relapses. In a few cases, large areas of plaque can persist for years.

  • Psoriasis nearly always goes into remission, however, often clearing spontaneously. In one study, 30% of patients reported untreated psoriasis going into remissions that lasted from one to 54 years.


Severity of Psoriasis


Severity of psoriasis ranges from one or two flaky inflamed patches to widespread pustular psoriasis that can be life threatening. The skin is usually categorized as mild to severe depending on the extent of the psoriasis to help determine treatment:
  • Mild psoriasis affects less than 5% of the body surface. Most cases of psoriasis are limited to less than 2% of the skin.

  • Moderate psoriasis covers 5% to 20% of the skin. (Some experts believe the cut-off should be lowered to 10%, particularly when psoriasis involves hands or feet.)

  • In general severe psoriasis affects over 30% of the body. Wide-spread psoriasis (erythrodermic psoriasis and generalized pustular psoriasis) can be life threatening. Fortunately these occurrences are rare. Only about 400 people die annually from complications of severe psoriasis.
About 5% of cases fall into the moderate to severe category, which extends beyond 20% of the skin's surface.

Some forms of psoriasis can be very resistant to treatment even though they are not categorized as severe. They include the following:
  • Any psoriasis on the palms and soles.

  • Inverse psoriasis (which occurs in the folds of the skin.

  • Scalp psoriasis.

  • Psoriatic arthritis.


Emotional and Social Consequences


Effect on Quality of Life. The emotional and social consequences of psoriasis should not be underestimated.
  • Many patients suffer severe humiliation and depression if plaques are visible. Some even withdraw from society and become isolated.

  • Some patients are forced to leave their jobs and go on disability if the condition becomes incapacitating.
Researchers who have surveyed psoriasis patients on quality of life have reported the following:
  • Surveys of patients with psoriasis report a negative mental and physical impact that is nearly equivalent to that of other major chronic conditions, including cancer, high blood pressure, diabetes, heart disease, and depression.

  • In one study, 75% of patients reported that psoriasis undermined their confidence.

  • Another reported that 8% of people with psoriasis felt their life was not worth living.
Higher Risk for Substance Abuse. A number of patients, particularly men, use alcohol and smoking as self-medication to reduce the emotional consequences of psoriasis. In fact, studies published in 2000 have found that people with psoriasis are more likely to die from heavy drinking and smoking than from psoriasis itself. Smoking has also been cited as a risk factor, particularly for pustular psoriasis. Some experts believe that drinking and smoking may actually cause biological damage that contributes to the onset of psoriasis.


Skin Irritation


Even in its mildest form, psoriasis can still cause itching, burning, stinging, and bleeding. These symptoms can be very debilitating in more severe cases.


Folate Deficiency in Severe Psoriasis


Severe psoriasis can also cause folate deficiency, a B vitamin that is important for neurologic function, preventing birth defects, and preventing elevations of homocysteine, a factor that may play a critical role in heart disease.


Complications of Erythrodermic and Pustular Psoriasis


Impaired Temperature Regulation. Erythrodermic psoriasis, in which psoriasis covers the entire skin, can cause abnormalities in the body's ability to regulate temperature.

Zumbusch Psoriasis. A combination of erythrodermic and pustular psoriasis, causes a serious condition called Zumbusch psoriasis:
  • The condition can develop abruptly.

  • Symptoms may include fever, chills, weight loss, and muscle weakness.

  • Patients may develop excessive fluid build-up, protein loss, and electrolyte imbalances. In such cases, hospitalization is required. Fluid and chemical balances must be restored and temperature stabilized as soon as possible.
Zumbusch psoriasis can be life threatening, particularly in the elderly. The condition is very rare in children and if it occurs, tends to improve more quickly, possibly even without medication, than in adults.


Complications of Psoriatic Arthritis


Most cases of psoriatic arthritis (PsA) are mild disease, but complications can occur:
  • Severe joint deformity and destruction (called arthritis mutilans ) generally in the small joints of the hands and feet. Studies report an incidence of about 5% to 16% of patients. Psoriasis patients with other arthritic conditions (osteoarthritis or rheumatoid arthritis) in the joints of the fingers tend to have a higher risk.

  • People with PsA may have a higher risk for respiratory illnesses.
Some earlier studies indicated that patients with psoriatic arthritis had a shorter lifespan than the general population, but more recent ones have found no significant difference.


Complications from Treatment


Treatments for moderate to severe psoriasis are expensive and many are cosmetically unpleasant. Some have potentially very severe side effects that can harm organs and other parts of the body beyond the skin surface.


HOW IS PSORIASIS DIAGNOSED?


A microscopic examination of tissue taken from the affected skin patch is required to make a definitive diagnosis of psoriasis and to distinguish it from other skin disorders. Usually in psoriasis, the examination will show proliferation of dry skin cells but without many signs of inflammation or infection. Changes in the nails typical of psoriasis are often strong indicators of psoriasis.


Ruling Out Other Conditions


Distinguishing Psoriasis Patches from Other Disorders. A number of skin conditions resemble psoriasis. Examples include the following:
  • Seborrheic psoriasis is hard to distinguish from seborrheic dermatitis (dandruff is one form of this condition). Seborrheic dermatitis patches are usually greasy, yellowish, and crusty. Nail involvement may also help differentiate psoriasis.

  • Exfoliative erythroderma may be confused with drug allergic reactions, atopic eczema, and symptoms of lymphomas.

  • Fungal infections, other skin conditions, or circulation problems may also cause nail changes typical of psoriasis.
Distinguishing Psoriatic Arthritis from Other Conditions. Psoriatic arthritis may resemble the following:
  • Rheumatoid arthritis (RA). As in rheumatoid arthritis, psoriatic arthritis can cause pain or tenderness in one or more joints and morning stiffness is common. People with psoriatic arthritis, however, lack a particular antibody, called rheumatoid factor, which is found in the blood of many people with rheumatoid arthritis.

  • Systemic lupus erythematosus (SLE). Symptoms of SLE may include both a psoriasis-like rash and arthritis, which could make the diagnosis difficult.

  • Reiters disease. Reiters disease is a syndrome that includes arthritis and inflammation in the eyes and urinary tract. It also causes skin lesions that are very similar to psoriasis, which are usually raised patches on the lips, penis, palms, and soles.

  • Gout. Gout causes pain, often in the fingers and toes.
Some evidence now indicates that psoriatic arthritis may be distinguished from other arthritic conditions by inflammation in sites where muscle tissue inserts into the bone (called enthesitis) rather than in the joint, which is a common site in other inflammatory arthritic conditions.


WHAT ARE THE GENERAL TREATMENT GUIDELINES FOR PSORIASIS?


Many medications used topically (on the skin) or orally are available for the treatment of psoriasis. Many patients require only over-the-counter treatment or even none at all during relapses. About a third of patients with psoriasis, however, do not respond to over-the-counter remedies and lifestyle changes and require aggressive treatments. In some cases, such treatments need to be life long.


Treatment Options


In general, the following three treatment options are used for psoriasis from least to greatest potency:
  • Topical Medications . Options include lotions, ointments, creams, and shampoos. These may be useful for mild-to-moderate psoriasis. Topical medicines rarely produce complete clearance, however.

  • Phototherapy. Options include light-wave radiation treatments using ultraviolet B (UVB) or psoralen with ultraviolet A (PUVA). This therapy is effective for moderate-to-severe psoriasis. In a 1999 study, phototherapies were much more effective than systemic drugs in achieving the longest remission. It also appears to have fewer side effects than most systemic agents. Even more promising, in a 2000 analysis comparing a number of psoriasis treatments, an advanced phototherapy called narrow band UVB achieved the highest complete clearance rate (86% of patients). (New lasers using UVB may even be more effective for certain patients.)

  • Systemic Agents . This treatment employs various oral drugs that affect the whole body system, not just the skin. These agents have significant side effects and are generally reserved for severe psoriasis.
Controlled comparison studies are needed to determine the safest and most effective treatments. In any case, individual requirements vary widely and treatment selection must be carefully discussed with the physician.


Treatment Sequences


Administering therapies in a specific sequence is a strategy for providing both quick relief of symptoms and long-term maintenance. It involves three main steps:

1. The quick fix is to clear the psoriatic lesions during an acute outbreak.

2. The transitional phase is intended to gradually introduce the maintenance drug.

3. On-going maintenance therapy.

Choices for transitional or maintenance regimens depend on the severity of the condition. Some examples are described in the following sections. It should be noted that combination treatments are increasingly used rather than single agents. Thousands of combinations are possible, and the patient and physician should discuss the most beneficial for individual needs.

Topical Regimen. Topical regimens are used for mild to moderate psoriasis.

An example of a topical regimen that uses a single agent is as follows:
  • A high-potency topical corticosteroid, such as halobetasol (Ultravate) used daily until the psoriasis plaque flattens out.

  • After that the steroid is applied only on the weekends for maintenance.
Another, possibly more effective, topical regimen uses the following combination for maintenance:
  • A high-potency steroid (halobetasol) on the weekend.

  • The vitamin D3 topical agent, calcipotriene, twice daily on weekdays.
In one study, over three quarters of patients with mild to moderate psoriasis remained in remission with this regimen for at least six months.

Systemic Regimens. A systemic regimen for more severe psoriasis uses the following agents:
  • The regimen starts with cyclosporine (known as an immunosuppressant).

  • Acitretin, a vitamin A derivative, is added during the transitional phase.

  • If the drugs are effective, the cyclosporine is withdrawn gradually after a few months and acitretin continues at as low a dose as possible.

  • PUVA is added if acitretin cannot control psoriasis.


Rotational Therapy


In severe chronic cases, a physician may recommend rotational therapy. This approach alternates treatments. The goal is to prevent severe side or tolerance effects from prolonged use of a single agent. An example of a rotational schedule may be the following:
  • Phototherapy is administered for about two years and stopped.

  • One or two powerful systemic drugs are then administered for one or two years and withdrawn.

  • Phototherapy is started again and the cycle is repeated.


WHAT ARE THE TOPICAL THERAPIES FOR PSORIASIS?


Topical medications are those applied only to the surface of the body. They come in the following forms:
  • Ointments.

  • Creams.

  • Sprays.

  • Scalp lotion.

  • Shampoos.

  • Occlusive tapes [ see Box Occlusive Tapes].
In general, topical treatments are the first line for mild to moderate psoriasis, but they may also be used alone or in combination with more powerful treatments for moderate to severe cases.


Topical Corticosteroids


Benefits. Corticosteroid topical treatments are commonly used because of the multiple benefits, including the following:
  • Reduce inflammation.

  • Inhibit cell proliferation.

  • Alleviate itching. (Sometimes itching can also be a side effect of the drug itself, however.)
Brands differ in potency and many are available. Some are now deliverable in foam preparations, which makes compliance much easier. They are generally given as follows:
  • Less potent drugs should be used for mild to moderate psoriasis.

  • High potency for more severe conditions.
In most cases, resistance to these drugs eventually develops or the disease recurs after treatment is stopped. [For specific brands and potencies, see Box Some Topical Corticosteroids Used for Psoriasis.]

Side Effects. The more powerful a drug the more effective it is but also the higher the risk is for severe side effects. They can include the following:
  • Burning.

  • Irritation.

  • Dryness.

  • Acne.

  • Thinning of the skin.

  • Dilated blood vessels.

  • Loss of skin color.
Corticosteroids should not be used during pregnancy or when nursing. The high-potency drugs carry a small risk for adrenal insufficiency . If this occurs, the body loses its ability to produce natural steroid hormones for a period of time after the drug has been withdrawn, which can cause serious complications.


Some Topical Corticosteroids Used for Psoriasis


Low potency Hydrocortisone (Hytone, Penecort, Synacort, Cort-Dome, Nutracort).

Desondide (Tridesilon).

Flumethasone pivalate (Locorten).

Fluocinolone acetonide (Synalar, Derma-Smoothe).
Low to medium potency Alclometasone dipropionate (Aclovate). Hydrocortisone (Locoid, Pandel).

Desonide (Tridesilon).

Hydrocortisone valerate (Westcort)
Medium potency Clocortolone pivalate (Cloderm).

Fluticasone propionate (Cutivate). A low-dose ointment (0.005%) is proving to be effective for psoriasis on the face and in folds of the skin, but not in other areas
High potency Halobetasol propionate (Ultravate).

Clobetasol propionate (Temovate).

Betamethasone (Diprolene). (Available as a foam for the scalp. In one 1999 study, 72% of patients were clear or almost clear of disease after 28 days of treatment, compared with 47% who were clear after using the lotion.)

Diflorasone diacetate (Florone, Maxiflor, Psorcon).

Mometasone furoate (Elocon). (Only needs to be administered once a day. May be as or more effective than corticosteroids at the same strength while having a lower risk for severe side effects.)


Tar


Tar preparations have been used for psoriasis for about 100 years. Crude coal tar inhibits enzymes that contribute to psoriasis and helps prevent cell proliferation. Tar is often used in combinations with other drugs and with ultraviolet B (UVB) phototherapy. [ See What Are Phototherapy Treatments for Psoriasis?, below.]

Side Effects. Preparations have the following drawbacks:
  • The drug can cause sun sensitivity and increase the risk for sunburn for up to 24 hours after use.

  • It has a strong smell.

  • It can stain clothing.

  • It irritates the skin.

  • Ingesting the medication is life-threatening. In such cases poison control should be called immediately.


Anthralin


Benefits. Like coal tar, anthralin (Dritho-Scalp, Drithocreme, Micanol), called dithranol in Europe, is a traditional medication, in use since the early 1900s. It appears to benefit patients with psoriasis by slowing skin cell reproduction. Remissions can last for months. Anthralin is recommended only for chronic or inactive psoriasis, not for acute or inflamed eruptions.

Forms. The most effective form is a hard paste, which patients find difficult to use compared to ointment and cream preparations. (Anthralin, however, offers fewer benefits in the easier-to-apply forms.) Alternatives being investigated are the following:
  • An encapsulated form (Micanol) may prove to be effective while being less irritating and cause less staining than the hard paste.

  • A 1% anthralin ointment has been tried in a method called short-contact therapy. It is applied for only one-half hour to two hours, after which the medication is removed and the area washed thoroughly.
Application. In all cases anthralin should be applied carefully. The following are some suggestions for application:
  • Because anthralin can irritate normal skin, it should not be used on the face.

  • After the paste is applied, affected areas are powdered with talcum and wrapped in a dressing to protect surrounding areas.

  • Hands should be washed thoroughly after use.

  • Anthralin can stain hair, fabrics, plastics, and other household products. Sinks or tubs or any other product used during the application should be rinsed with hot water immediately and then followed by the use of a cleanser.
To apply anthralin to the scalp, the following is recommended:
  • The psoriatic areas should be soaked first in warm mineral oil.

  • The hair is combed to remove any scaly debris.

  • It is then parted to expose the areas of plaque.

  • The anthralin solution is applied only to the patches and rubbed well.

  • Patients should be sure that the medication does not spread to the forehead or exposed areas.
Side Effects
  • Skin irritation and burning. It should not be used on the face. Fair skinned people should generally avoid it.

  • Brown staining.

  • Although topical preparations do not appear to affect areas other than the skin, people with kidney problems are advised to use anthralin with caution.


Topical Vitamin D3 Analogs


A topical form of vitamin D3, calcipotriene (Dovonex), called calcipotriol in Europe, is proving to be both safe and effective.

Benefits. Calcipotriene has the following benefits:
  • It appears to help block skin cell proliferation.

  • It enhances the maturity of keratinocytes (the impaired skin cell in psoriasis).

  • It has anti-inflammatory properties.
It is at least as effective as the potent topical corticosteroids, short contact anthralin, and coal tar in improving mild to moderate plaque psoriasis. Improvement occurs between two and six weeks and most cases of psoriasis clear by 14 to 36 weeks after treatment. Compliance is very good. It is now available in a foam preparation, which makes compliance even easier. Several other vitamin D3 analogs, such as maxacalcitol and talcalcitol, are also showing promise.

Side Effects. They include the following:
  • Calcipotriene causes skin irritation in about 20% of patients and so should not be used on the face. In fact, it causes greater skin irritation than potent corticosteroids. This rarely causes a patient to stop using the drug.

  • Although the drug appears to be safe and effective in children, there is some concern that it may lower levels of vitamin D to the extent that they affect bone growth. More studies are needed to determine this effect.


Topical Retinoids


Retinoids are vitamin A derivatives and are being used for various skin disorders. Tazarotene (Tazorac, Zorac) is the first topical retinoid found to be effective for mild to moderate psoriasis.

Benefits. Tazarotene gel benefits the targeted skin tissue without causing the adverse systemic effects of oral retinoids. One study reported that improvements occurred within a week of treatment, and depending on the potency, the drug was successful in 59% to 70% of patients. It can irritate the skin, but overall it is very safe. It should be noted, however, that when used alone it is less effective than many other treatments. Combinations, such as with topical steroids or phototherapy are more effective.

Tacrolimus

Tacrolimus (Protopic) is a topical agent that suppresses immune factors. It may help clear psoriasis lesions without the adverse effects that corticosteroids have. Initial results are promising and further study is underway. Although approved for eczema, the ointment is not yet indicated for psoriasis so it is not covered by most insurers.



Occlusive Tapes


Watertight (occlusive) tapes may help heal psoriasis and are particularly useful for psoriatic cuts on the palms and soles. (In such cases, the tape should be applied across the cuts until they heal.) Occlusive tapes retain sweat, which helps restore moisture to the outer skin layer and prevent scaling. They also protect against abrasion and irritation.

High-Potency Corticosteroid Tapes. Applying a corticosteroid beneath an occlusive tape or using one already impregnated with a potent corticosteroid (Cordran Tape), such as flurandrenolide, may be especially beneficial. Studies are showing that high-potency corticosteroid-impregnated tapes are more effective than using high-potency corticosteroid ointments alone. The downsides are the following:
  • The corticosteroid-impregnated tape is expensive.

  • It produces a higher incidence of skin irritation than the ointment alone.

  • It produces more pronounced rebound effects than the ointment (a relapse of symptoms after stopping treatment).

  • Steroid-impregnated tapes increase the risk for secondary infections, which may be prevented by changing the tapes every 12 hours.

  • The use of corticosteroids under occlusive materials on large areas of psoriasis increases the risk for adrenal insufficiency, a sometimes dangerous condition that occurs because the body loses its ability to produce natural steroids. Children are especially susceptible.
Fluorouracil with Occlusive Tapes. One study applied a cream containing fluorouracil underneath an occlusive tape. The dressing was applied two or three times a week for an average of about 16 weeks and resulted in 90% clearing in 11 out of 15 patients. Improvement persisted beyond three months in five patients.

 


WHAT ARE THE SYSTEMIC TREATMENTS FOR PSORIASIS?


Systemic treatments involve oral or injected drugs, which affect the entire body. Many of the systemic drugs used for psoriasis are also used for other severe diseases, including autoimmune diseases (especially rheumatoid arthritis) and cancer. Nearly all are powerful medications with potentially serious side effects. These drugs should be used only for severe incapacitating cases of psoriasis that do not respond to lifestyle changes or topical (or other less potent) therapies.

As with all agents used for psoriasis, the least potent agents should be used first:
  • Methotrexate and retinoid are the first-line, or primary, oral drugs for adults with severe psoriasis. Cyclosporine may be considered as first-line therapy for children with severe psoriasis.

  • Second-line drugs include hydroxyurea, sulfasalazine, and thioguanine.

  • Third-line agents include tacrolimus.


Methotrexate


Methotrexate (Rheumatrex) is very effective for severe psoriasis. For example, one center reported that 80% of patients reported prolonged improvement. It has the following beneficial properties:
  • It interferes with cell reproduction.

  • It has anti-inflammatory properties.

  • It is one of the few systemic agents proven to help patients with psoriatic arthritis.
It is important to note that the recommended dose is taken weekly, not daily. Fatal toxicities have been reported in people who mistakenly took it once a day.

Side Effects.
  • Common side effects of methotrexate are nausea and vomiting, rash, mild hair loss, headache, and mouth sores. It may also cause muscle aches. (Many of these symptoms are due to folic acid deficiency. Patients should ask their physician about supplements to offset these symptoms.) Patients who experience nausea may opt for injections, which are effective and less expensive than oral agents.
More serious complications include the following:
  • Kidney abnormalities and liver scarring. People at particular risk for liver damage from methotrexate include diabetics with existing liver or kidney problems, alcoholics, those who are obese, and the elderly. Regular monitoring for liver toxicity is important.

  • Suppression of blood cell production in the bone marrow.

  • Osteoporosis.

  • Increased risk for infections, particularly herpes zoster and pneumonia.

  • Lung disease occurs in up to 5% of people who take methotrexate and deserves special mention. There are five key risk factors for methotrexate-induced lung diseases: age, diabetes, existing rheumatoid involvement in the lung, protein in the urine, and previous use of other DMARDs, particularly sulfasalazine, oral gold and d-penicillamine. Patients with multiple risk factors should report any symptoms, such as coughing, that might indicate lung injury.

  • Severe anemia from folic acid deficiencies. Supplementation with folic acid while taking methotrexate can prevent this side effect.

  • There have been a few reports of lymphomas in some patients taking methotrexate; in such cases, the disease appears to go into remission when the drug is stopped. Most studies have found no significant risk for cancer in patients taking this agent.

  • Patients taking methotrexate should not take nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil), or naproxen, which can cause serious toxic interactions. (It should be noted that rheumatoid arthritis patients who take methotrexate often also take NSAIDs, but methotrexate doses for psoriasis are usually much higher.) Patients should ask their physicians about any other drug interactions.
Pregnant and nursing mothers should never take this drug, which increases the risk for severe, even fatal, birth defects and miscarriage. Other people who should avoid methotrexate are those with psoriasis who also have impaired immune systems, peptic ulcers, active infectious diseases, rheumatoid arthritis, or anemia or other blood abnormalities. Methotrexate appears to be effective in children, but more safety research is needed.


Oral Retinoids


Oral retinoids (derivatives of vitamin A) include etretinate (Tegison), acitretin (Soriatane), and isotretinoin (Accutane). Acitretin is the retinoid of choice and is effective for severe psoriasis, particularly pustular variants. Etretinate is useful for patients who are HIV positive. Accutane is sometimes used but is far less potent than acitretin.

Benefits. Oral retinoids have the following beneficial properties for patients with psoriasis:
  • They have anti-inflammatory actions.

  • They help regulate cell reproduction.

  • They may even improve arthritis that accompanies psoriasis.
Combinations. Many experts now believe that acitretin is not very useful as a single agent but can be very effective in combination with other agents, usually topical agents and especially with phototherapy. Acitretin and phototherapy, in fact, have some of the highest clearance rates of any treatment. In addition to combination treatments, some experts recommend the following to reduce toxic effects of acitretin:
  • Maintenance doses should be as low as possible and should be taken every second or third day.

  • Patients aim for a low-fat diet and engage in daily aerobic exercise to maintain healthy triglyceride levels.

  • Fish oil supplements may be very helpful.
Side Effects. Children and women who wish to bear children should not take these agents. All retinoids have the same potentially serious toxicities as do high doses of vitamin A:
  • Common side effects include dry nose, dry eyes, chapped lips, bone and joint pain, thinning hair, fatigue, peeling of the palms and soles, nose bleeds, bruising, and headache.

  • Of special note, retinoids pose a significant risk for birth defects when taken by pregnant women. [See Box Retinoids and Pregnancy.]

  • The drugs may cause eye problems, including blurred vision, cataracts, and a sudden deterioration in night vision.

  • Retinoids carry a high risk for increased bone growth, particularly in the ankles, pelvic area, and knees.

  • They increase triglyceride levels, which are proving to be significant risk factors for heart disease.

  • In rare cases, they may cause a condition called benign intracranial hypertension, which occurs in the brain. Symptoms include headache, nausea, vomiting, and blurred vision. Patients experiencing these symptoms should call the physician immediately and stop taking the drug.

  • The drugs also can cause damage to the liver.



Oral Retinoids and the Pregnant Patient


Retinoids taken by pregnant women pose a significant risk for severe birth defects in the unborn child. Pregnant or nursing women should not use either acitretin or etretinate, although there are some difference.

Etretinate. Etretinate is stored in fat cells for up to three years, so women should not become pregnant for at least that long after discontinuing the drug.

Acitretin. Acitretin is cleared from the body more rapidly than etretinate and becomes undetectable in about three or four weeks, so it appears not to pose a long-term risk for birth defects.

There is one important exception: Drinking alcohol converts acitretin to etretinate. Therefore, if a woman drinks alcohol while taking acitretin or any time during the two months after she stops, she must wait three years to conceive.




Cyclosporine


 

Cyclosporine. Cyclosporine (Neoral, Sandimmune, SangCya) blocks certain immune factors and is known as an immunosuppressant. Neoral is the preparation used most often for psoriasis. Studies report that it clears psoriasis in between 60% and 80% of patients within eight to 12 weeks. A new microemulsion formulation (Neoral-Neo) may be safe for patients with erythrodermic psoriasis. It can be used alone or in combination with topical agents in certain circumstances.

It has significant side effects, and should be reserved for patients who did not response to phototherapy or less potent systemic agents (eg, methotrexate or acitretin). Side effects include the following:
  • Common and temporary side effects. Headaches, gingivitis, joint pain, gout, body hair growth, tremor, and fatigue.

  • High blood pressure (occurring in up to 30% of patients). Some experts advise treating any high blood pressure with calcium-channel blockers, since other standard anti-hypertensive drugs may worsen psoriasis.

  • It increases the risk for unhealthy cholesterol and lipid levels.

  • Prolonged use always causes some kidney damage.

  • It causes abnormalities in the liver.

  • Because it suppresses the immune system, cyclosporine also increases the risk for infections.

  • Long-term use may increase the risk for skin cancers and lymphomas, particularly in patients who have had other psoriasis treatments, including PUVA, tar, or radiation therapy, methotrexate, or other immunosuppressant drugs.

  • Cyclosporine interacts with many drugs, including some over-the-counter preparations. Patients should discuss all medications with their physician. Grapefruit and grapefruit juice contain psoralens, which can increase concentrations of the drug, and should be avoided.
Patients should be monitored regularly for hypertension and signs of kidney or liver abnormalities. To minimize complications of cyclosporine, the dosage is reduced after improvement occurs. Maintenance therapy is usually limited to a year, although some experts say that the microemulsion form of Neoral is safe for up to two years.


Second- and Third-Line Systemic Agents


Second- or third-line agents are used alone or sometimes in combination with first-line systemic drugs if they fail. They are generally less safe than first-line agents.

Hydroxyurea. Hydroxyurea (Hydrea) appears to inhibit cell reproduction and also increases water content in red blood cells. The drug can lower blood cell counts, causing anemia and possibly increasing the risk for infection. Other side effects include gastrointestinal problems, leg ulcers, and skin rash. In some patients it may cause dark coloring of the nails. Pregnant or nursing women should not use it. Thioguanine. Thioguanine (Tabloid) is an immunosuppressant used in cancer treatments and has actions against T-cells. Small studies are reporting it to be effective for patients with moderate to severe plaque psoriasis. In a small 2001 study, 78% of patients reported dramatic improvement (90% or greater clearing of their lesions) during 15 months of treatment. This drug suppresses blood cell production and can cause liver and gastrointestinal damage, although the risk does not appear to be significant in psoriasis patients.

Azathioprine. This agent may be helpful in allowing a lower dose of cyclosporine.

Sulfasalazine. Sulfasalazine (Azulfidine) was developed in the 1930s for treating rheumatoid arthritis and is sometimes used for psoriasis. In one major analysis, sulfasalazine and methotrexate were the only agents proven to help patients with psoriatic arthritis.

Zidovudine. Zidovudine, also known as AZT, may be effective for patients with AIDS-induced psoriasis. Studies have found that it helps improve the condition in cases of severe pustular psoriasis that does not respond to etretinate.

Mycophenolate mofetil (MMF). MMF has been disappointing and some experts recommend it only as an added drug in patients who do not respond to methotrexate or cyclosporine.


Biologic Response Modifiers


Biologic response modifiers are genetically engineered drugs that interfere with specific components of the autoimmune response. Because of their precise targets, these drugs do not damage the entire immune system the way that general immunosuppressants do. They are the first agents to produce the dramatic effects originally seen with corticosteroids.

Agents Targeting Tumor Necrosis Factor. Infliximab (Remicade) and etanercept (Enbrel) have actions against tumor necrosis factor (TNF), an cytokine that is important in the disease process. Both have been approved by the FDA for treating rheumatoid arthritis. They appear to have benefits for psoriasis as well. For example, in a small 2000 study, patients with psoriatic arthritis who used infliximab for 10 weeks reported dramatic improvements, and after one year, two thirds of patients had no swollen or tender joints.

Agents Targeting T-Cells. A number of important medications under investigation target helper T-cells. These are critical immune factors that researchers believe trigger the psoriasis disease process. Drugs that specifically target these molecules may be able to shut down part of the disease process without causing side effects.

Alefacept (Amevive), a drug that blocks T-cells, is showing promise in late clinical trials for achieving remission without early relapse in some patients. In one study, 34% of patients experienced improvement of about 75%, and in a 2001 trial, 24% reported complete or near complete clearance. .Others T-cell blockers under investigation and showing promise include ascomycin macrolactam (ASM-981) and hu1124.

Agents Targeting Interleukins. Interleukins are other powerful inflammatory agents of the immune system. Interleukins being investigated include IL-2 IL-8, IL-11, and IL-12. For example, daclizumab is an engineered antibody designed to block IL-2, a major stimulus for T-cell growth. Someday, it may prove to be useful in psoriasis.


Experimental Treatments


Omega-3 Fatty Acid. Fish oil has been studied because it contains omega-3 fatty acids, which help block inflammation. Taking supplements of fish oil do not appear to provide any benefits. In one 1998 study, however, omega-3 fatty acids from fish oil were administered intravenously; severity was reduced by half in 37% of these patients compared to 23% in patients receiving omega-6 fatty acids (which are contained in many plant oils).

Colchicine. Colchicine is an ancient drug long used to treat gout, and small studies are now suggesting that it is effective for treating severe psoriasis. It is particularly effective when used in solution with occlusive dressings. It is also helpful for psoriatic arthritis, although in such cases, it does not appear to improve skin lesions. A 1999 study suggests that colchicine may be effective in patients who also have renal amyloidosis, an uncommon but serious syndrome involving the kidney that is sometimes associated with psoriasis. Unfortunately, high doses of this drug are not suitable for many patients because of side effects such as nausea, vomiting, diarrhea, or abdominal cramps.

Thiazolidinediones. Thiazolidinediones are drugs that increase sensitivity to insulin and are used to treat diabetes type 2. They also affect receptors for vitamins A and D. In one study patients who took troglitazone (Rezulin) experienced significant improvement in their symptoms. (Troglitazone has been discontinued for diabetes in the US because of liver toxicity, but this study warrants further research.)



WHAT ARE THE PHOTOTHERAPY TREATMENTS FOR PSORIASIS?



General Recommendations for Phototherapy


Description of UVA and UVB Radiation. The two phototherapy treatments for chronic cases of psoriasis employ ultraviolet B (UVB) or ultraviolet A (UVA) radiation. Both UVA and UVB radiation are components of sunlight.
  • UVB is the primary agent in sunburning and primarily affects the outer skin layers.

  • UVA penetrates more deeply and efficiently.
When sunlight penetrates the top layers of the skin, ultraviolet radiation bombards the genetic material, the DNA , inside the skin cells and injuries it. It also impairs immune function in the skin. Such effects are the cause of wrinkles, aging skin disorders, and skin cancers. These same damaging effects, however, can also destroy the skin cells that form psoriasis patches.

Although both UVA and UVB can destroy psoriasis skin cells when used in phototherapies, there are some differences:
  • UVB is about 1,000 times more powerful than UVA in producing sunburn. Mild pink skin (erythema) caused by UVB, in fact, can be effective against psoriasis. The same skin tone caused by UVA alone, however, does little good.

  • UVB may be used alone while UVA requires a photosensitizing medication to be effective. However, this combination UVA treatment, called PUVA, is generally much more potent than standard UVB therapies.

  • UVA poses a higher risk for skin cancers, including melanoma, than UVB.

  • Home use of UVB requires a physician's prescription. UVA units are available without prescription for home tanning and in tanning salons, although experts rarely recommend such treatments because of the cancer risks from over-exposure and the lack of benefit without medication.
The use of UVB and PUVA varies widely, with some centers using PUVA and others relying more on UVB. One 1999 study indicated that the use of UVA or UVB therapies tends to be based on geographic, racial, economic, and other factors rather than on conclusive evidence regarding the benefits for specific types of psoriasis.

People Who Should Avoid Phototherapy. T he following patients should avoid phototherapy.
  • People with very severe psoriasis.

  • Patents who are sensitive to sunlight.

  • Possibly people with HIV infection. One small study suggested that exposure to ultraviolet radiation may worsen HIV. Antiviral therapy can help protect such patients who need phototherapy. (This study may also have implications for sun exposure in HIV-positive people.)


Broadband Ultraviolet B (UVB) Radiation


Broad spectrum UVB is radiation measured at 290 to 350 nm and has been the standard UVB phototherapy treatment. (UVB radiation below measurements of 300 nm is toxic but not effective, while radiation above 300 nm is more therapeutic.) Broad spectrum UVB phototherapy may be administered as follows:
  • Using UVB radiation alone.

  • UVB treatment with coal tar (the Goeckerman regimen).

  • UVB with anthralin (the Ingram regimen).
These are effective treatments for local or widespread psoriasis that cannot be managed with topical preparations alone. The procedure differs depending on whether it is used with medication or without. The use of retinoids, such as a tazarotene gel or oral acitretrin, is proving to increase its effectiveness.

Broadband UVB Procedures Used Without Medication. When used without medication (known as selective ultraviolet phototherapy) UVB treatment generally is administered as follows:
  • Treatment can be administered in the physician's office or at home with equipment obtained using a physician's prescription. Even at home, treatment must always be supervised, however.

  • UVB therapy usually requires about 20 to 40 treatments (about three per week).

  • Full results take about three weeks.

  • Maintenance treatment is given twice weekly for one to two months and then once a week for about four months. This is generally effective in preventing relapse.
Broadband UVB Procedures Used With Medication. When combined with coal tar or anthralin, UVB may be administered as follows:
  • Treatment is administered in a psoriasis day care center. These centers are located only in certain cities, however, and treatment there may not be covered by insurance.

  • This combined therapy requires a full eight hours for a single treatment.

  • Treatments may need to be administered daily for two to four weeks.
Studies indicate that a low-dose (1%) coal tar preparation is as effective as high-dose (6%). Another study, in fact, reported that using a simple emollient (a skin softener) and administering aggressive UVB radiation until the skin is red was as effective as using coal tar with less aggressive UVB.

Side Effects of UVB. It has not been thought that UVB treatments pose any risk for skin cancers except on male genitalia. One study reported, however, that melanoma developed in human tissue exposed to UVB radiation. Furthermore, a 1999 study suggested that UVB treatments probably cause up to two nonmelanoma skin cancers per 100 patients. Some experts postulate, on the other hand, that UVB therapy may actually have protective properties, since doses are generally low and it causes the skin to thicken but does not burn the skin, a primary trigger for skin cancer.


Narrow Band Ultraviolet B (NB-UVB)


Narrow band (NB) UVB radiation uses fluorescent lighting that emits radiation in a specific range between 310 and 312 nm, which, theoretically is the most beneficial component of sunlight. It is the primary UVB treatment in Europe and is gaining wide acceptance in the US. The following are the advantages of NB-UVB:
  • Exposure times are shorter but of higher intensity than with broadband UVB.

  • It is nearly as potent as PUVA therapy and is most likely safer.

  • It is very efficient in reducing T-cells in the skin (the immune factors responsible for psoriasis).

  • The course of treatment is shorter.
On the negative side, remission times are not as long with NB-UVB as they are with PUVA. One 1999 comparison study reported that only 12% of those treated with narrow band UVB were clear of psoriasis 6 months after finishing treatment compared with 35% from PUVA. Combinations with topical agents, such as tazarotene or psoralens, may improve its effectiveness and increase remission times.

One expert suggests the following treatment schedule:
  • Treatments are performed three times a week to start.

  • Clearance of 75% typically occurs after 10 to 12 treatments.

  • Thereafter, maintenance treatments are given once a week.
Laser UVB Treatment

Laser treatments are now available that deliver a precise UVB wavelength of 308 nm. It targets very specific areas of skin and avoids exposing healthy skin to UV rays. This may be more effective than narrow-band UVB for localized psoriasis. Generally, four to six treatments are needed to clear psoriasis and remissions lasting for months have been achieved with six to eight treatments. One 2000 study suggested that some patients may require only one treatment to achieve moderately prolonged remission. The high levels needed to clear psoriasis in a single treatment, however, can also increase the risk for skin cancer.


Psoralens and Ultraviolet A Radiation (PUVA)


PUVA treatments employ a combination of a psoralen drug and ultraviolet A (UVA). Forms of psoralen include methoxsalen, 8-methoxypsoralen (8-MOP), or bergapten (5-MOP). The effectiveness of the treatment is based on a chemical reaction in the skin between the psoralen and light. It works in the following way:
  • Psoralen is usually taken orally and is administered before the treatment starts. Psoralen reaches the skin through the blood stream where it increases the skin's sensitivity to UVA radiation. (Topical preparations of psoralen are also available that can be "painted on" or applied to the affected areas by soaking or bathing in a psoralen solution. PUVA-bath therapy may be especially useful for persistent psoriasis on the palms and soles.)

  • Inflammation and redness in the skin develop within two to three days after treatment.

  • Such damage inhibits skin cell proliferation.
People should avoid this treatment if they are taking drugs or have conditions that cause them to be light sensitive. The should also take protective measures before, during, and after each treatment. [ See Box Protective Measures with PUVA Therapy.]

Initial PUVA Treatment Phase. The initial phase typically follows these steps:
  • Psoralen is taken with food or milk about two hours before UVA treatment.

  • The amount of time a person is exposed to UVA rays depends on the skin type. Fair-skinned patients are at higher risk for redness and burning than darker skinned patients and should receive lower doses of UVA. (Some studies have suggested that reducing the standard dose of UVA by one third or one half in everyone may yield the same benefits as full dosages. If effective, such reductions would beneficial given the long-term risks for skin cancers with PUVA.)

  • Treatments take about eight hours.

  • They may be repeated two or three times a week. They should never be performed more frequently than once every other day, since the full effects of the treatments are not evident for 48 hours.
It takes an average of about 30 treatments for full effect, but during that period, treatment intensity may vary:
  • If there is no response after 10 treatments, the physician may increase the UVA energy.

  • If there is still no response after 15 treatments, then the psoralen dosage may be increased.

  • If a patient's skin does not improve at all or worsens after these changes, then the treatment is temporarily stopped. PUVA may be causing a toxic response in such cases, and, often, the condition gradually improves over the following two weeks.

  • If the skin does not improve, then PUVA treatment is considered to have failed. If skin improves during this resting period, then treatment resumes.
Maintenance Phase. Once the psoriasis has improved by about 95%, the patient is put on a maintenance schedule:
  • The patient starts with weekly treatments.

  • They gradually become less frequent until they are administered only for flare ups.

  • As maintenance continues and treatment intervals become further apart, the patients may become more susceptible to tanning and sunburn. In such cases, exposure should be reduced by about 25% until the patient no longer experiences sunburn.
Side Effects of PUVA. Adverse side effects include the following:
  • Skin reactions, including itching, sunburn, and blistering. These can generally be avoided with careful administration of PUVA therapy and protective measures. [ See Box Protective Measures with PUVA Therapy.]

  • The psoralen methoxsalen causes malaise and nausea in 20% of patients. Another psoralen, Bergapten (5-MOP) may cause less nausea but is not yet available in America.

  • After treatment, white spots commonly develop where psoriasis plaques had occurred, particularly in people with naturally darker skin. If they are troublesome, tanning products may help darken them.
Long-Term Risks. UVA penetrates the skin more deeply than UVB, so there is a greater danger of deep skin damage and accelerated skin aging. It has been known for some time that PUVA can modify DNA and cause genetic mutations. Of concern, then, is an increased risk for cancers after PUVA treatment.

PUVA is known to increase the risk for squamous cell skin cancer and slightly increases the risk for basal cell skin cancer, both of which are nearly always curable. The risk is higher in the following patients:
  • Patients who have had over 200 treatments.

  • Patients with a family or personal history of skin cancer.

  • Patients with light skin and fair or red hair.

  • Patients who have had radiation or x-ray treatments or taken immunosuppressant drugs.
Even more worrisome was a study reporting an increased risk in melanoma, a very serious skin cancer.

Discussions are underway, in fact, about discontinuing PUVA for psoriasis.
  • Experts against PUVA argue that studies suggest a long-term risk for melanoma, starting about 15 years after treatment, particularly in people who receive more than 250 treatments. Although in one study only nine out of 1,380 patients developed melanoma, seven of these cases occurred in the last five years, indicating that the danger persists and more patients in this study are likely to develop this serious skin cancer as time goes on.

  • Experts supporting PUVA argue that it is not yet known if the people who developed melanoma experienced sunburn during the procedures or if they already had risk factors for skin cancers. If so, then properly administered treatments could still be considered safe for patients without risk factors. Such experts also argue that PUVA is still the most effective treatment for severe psoriasis, and the alternatives are usually very powerful and relatively new drugs that may have even more serious side effects.
[ See also Report #32, Melanoma.]


Protective Measures with PUVA Therapy


The side effects from UVA radiation can be severe and protective measures are needed during, before, and after treatment.

Protective Measures Before Treatment. Patients should avoid prolonged exposure to the sun for 24 hours before the oral treatment starts.

Protective Measures during Treatment. During PUVA therapy, the patient should take the following precautions:
  • They need to wear specially designed goggles to protect the eyes from UVA radiation.

  • Sensitive areas, such as genitals, abdominal skin, and breasts, are covered until tanning occurs in the exposed areas, after about a third of the treatment period. (Male genitals are covered throughout the process unless they are affected by psoriasis.)
The following safety features should be available in the PUVA chamber:
  • Lamps with protective shields.

  • A viewing window so that a health professional can check the patient periodically.

  • A door that can be opened by the patient easily and with little pressure.

  • A timer that terminates the session automatically.

  • An accessible alarm device.
Protective Measures After Treatment. The patient should take the following precautions after treatment:
  • As soon as the drug has been taken and for at least 24 hours after the combined treatment, patients should wear UVA absorbing wrap-around sunglasses that are designed to completely block out stray radiation. This is important to prevent a PUVA reaction around the eyes that can cause cataracts.

  • For about eight hours after taking the drug, patients must also avoid exposure to daylight, even if the day is cloudy or through windows.

  • Patients who must go out should wear heavy opaque clothing, including hats and gloves.

  • Sunblocks should be applied over all exposed areas, including the lips. The sunblock should have an SPF (sun protection factor) of more than 15 and include ingredients that block UVA radiation (eg, benzophenone, terephthalylidene dicamphor sulfonic acid, zinc or titanium oxide).

  • No patient should spend any prolonged time in sunlight for at least two days after the combined treatment.



WHAT ARE DIETARY AND OTHER LIFESTYLE FACTORS FOR MANAGING PSORIASIS?



Exposure to Sunlight


Although sunburn carries a risk for skin cancer and may actually exacerbate psoriasis, regular exposure to the sun helps clear psoriasis in people with mild to moderate conditions. Experts advise covering non-affected areas with clothing or sunscreen and sun bathing only until the skin starts to tan. Vacations in sunny areas, such as Hawaii or the Caribbean, can offer relief. For those who can afford it, a prolonged stay of several weeks at the Dead Sea in Israel has proven to significantly improve or clear 88% of those with psoriasis. The region offers a unique combination of intense but naturally filtered UVA radiation combined with minerals and salts from the sea.


Emotional Support


Because of the association between negative emotions and psoriatic flares, relaxation and anti-stress techniques may be helpful. Many are available. [ See Report on Stress.] The following are some studies suggesting that emotional support may have an impact on psoriasis:
  • One study investigated patients with psoriasis who discussed with a psychiatrist any traumatic or other intense event that occurred when the skin condition appeared. In the study, 68% of patients recalled such an event and 62% experienced significant improvement after the talk session.

  • Another reported that patients treated with antidepressants along with topical corticosteroids for psoriasis experienced greater skin improvement than those who took the steroid alone.

  • Hypnosis aimed at reducing stress may improve symptoms, according to a small 1999 study.


Treating Dry Skin


If skin becomes dry and itchy, the patient may try the following:
  • Soak in a warm bath for about 15 minutes.

  • Afterward, apply salicylic acid first, which removes scaly skin and may promote the penetration of both moisturizers and topical prescription medications.

  • Then, apply a thick moisturizer or emollient, such as Vaseline, Cetaphil cream, or Eucerin cream. (Lotions are not adequate moisturizers.)

  • Special gloves made of Gore-Tex (DermaPore) may be worn at night over a thick moisturizer cream. These gloves are protective but also allow moisture to escape.
Some experts suggest that many common moisturizers may actually increase water loss in psoriasis, but studies are needed to confirm this. In the meantime, if moisturizers help relieve the condition, then patients should use them.


Folic Acid


Patients should be sure they have sufficient folate, or its synthetic form folic acid. Folate is a B vitamin best found in liver, asparagus, fruits, green, leafy vegetables, dried beans and peas, and yeast. The FDA has ruled that folic acid supplements should be added to commercial grain products.


Alternative Remedies


Patients with chronic conditions may be tempted to try alternative or untested treatments, including herbs and other nontraditional therapies. Among those being tried for psoriasis are the following:
  • The herb mahonia aquifolium (Oregon grape root) has properties that are effective against some of the biologic activities causing psoriasis, including over-proliferation of keratinocytes. Small studies suggest it may be somewhat effective for some patients with moderate to severe psoriasis.

  • Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. It is used to relieve arthritic pain and may help reduce psoriatic itching and lesions. Capsaicin should be handled using a glove, and applied to affected areas three or four times daily. The patient will usually experience a burning sensation when the drug is first applied, but this sensation diminishes with use.

  • Gotu Kola (centella asiatica) may be effective as a topical application for psoriasis. The agent in oral form has serious side effects, however, including increasing the risk for miscarriage in pregnant women. As with all herbal products, no long-term studies have confirmed either the effectiveness or safety of this agent.

  • Anecdotal reports also suggest that some patients may benefit from taking garlic capsules. There is no scientific evidence for such benefits.

  • Other herbs traditionally used for psoriasis include milk thistle (silybum marianum), burdock (arctium lappa), red clover (trifolum pratense), and sarsparilla (smilax). There have been no clinical studies conducted to date on these remedies in psoriasis patients.
No one should use any so-called natural or unproven therapies without consulting their physicians to be sure such treatment is not harmful and does not interfere with any standard medications being taken. [ See Warning Box.]



Warnings on Alternative and So-Called Natural Remedies


It should be strongly noted that alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public.

There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication. Most problems reported occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals.

Of note for patients with psoriasis: A number of so-called natural products (Skin-Cap, Blue Cap, Miralex) have been sold for psoriasis that actually contain prescription-strength corticosteroids. Such steroids have the same side effects as those in standard psoriasis agents. These products have been banned in the US and Canada, but similar untested medications are available over the Internet.

The following website is building a database of natural remedy brands that it tests and rates. Not all are available yet. https://www.ConsumerLab.com/

The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to untested substances, such as herbal remedies and vitamins (call 800-332-1088).


WHERE ELSE CAN PEOPLE WITH PSORIASIS GET HELP?


National Psoriasis Foundation
6600 S.W. 92nd Avenue, Suite 300, Portland, OR 97223.
Call (503-244-7404) or (800/723-9166) or (https://www.psoriasis.org)


American Academy of Dermatology and American Society for Dermatologic Surgery
930 N. Meacham Rd., Schaumburg, IL 60168-4014.
Call (847-330-0230) or (888-462-3376) or (https://www.aad.org/)
and (https://www.asds-net.org).

The website specifically for psoriasis.
(https://www.derm-infonet.com/psoriasisnet/index.htm)


Good Internet Sites


ead Sea Psoriasis & Arthritis Treatment Foundation
(https://www.psoriasis-dead-sea.org/services.htm)

Psoriasis Genetics Laboratory at the University of Michigan. This web site
contains information about genetic research and psoriasis. On the internet
at (https://www.psoriasis.umich.edu/index.html)

Clinical Trial Sites

https://www.veritasmedicine.com/d_index_tc.cfm?did=202

https://www.centerwatch.com/patient/studies/cat126.html

https://www.biospace.com/ct/list_indication.cfm


 

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