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Definition of Psoriasis
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.
it is believed that these destructive changes originate from genetic
abnormalities in the immune system that are triggered by environmental
- 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.
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.
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.]
of Plaque Psoriasis Patches. It is described as follows:
develops in the following locations:
- 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.
usually appear symmetrically, that is, in the same areas on
opposite sides of the body.
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).
Location of Plaque Psoriasis. They most often occur on the
elbows, knees, and the lower back.
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.
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.
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.
(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
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. 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.
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.
Infrequently, the course of PsA has been associated with a syndrome
known by the acronym SAPHO, whose letters form the symptoms:
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.
(inflammation in the joints).
(abnormal bony growths).
Common Forms of 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
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
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 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.
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
The nail bed often separates from the skin of the finger
and collections of dead skin can accumulate underneath
Over half of patients with psoriasis have abnormal changes
in their nails.
Such nail changes may appear before psoriatic skin eruptions
In some cases, nail psoriasis is the only type of psoriasis.
Generalized Erythrodermic Psoriasis. (also called psoriatic
In rare severe cases, psoriasis develops into generalized
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
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
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
A number of conditions may trigger pustular, including the
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.
Response and Autoimmunity
Immune System Response. The inflammatory process is a byproduct
of the body's immune system, which fights infection and heals wounds
Fighters. The primary infection-fighting units are two types
of white blood cells: lymphocytes and leukocytes.
- 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
- In the
process, the surrounding area becomes inflamed and some healthy
tissue is injured.
normal conditions, the immune system has other factors that
control and limit this inflammatory process.
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:
T-cells are further
categorized as killer T-cells or helper T-cells (TH cells).
produce antibodies, which are separate agents that can either
ride along with a B-cell or travel on their own to attack the
have special receptors attached to their surface that recognize
the specific antigen.
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:
T-cells directly attack antigens that occur in any cells that
contain a nucleus.
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
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
- 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.)
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.
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.
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
which attract even more white blood cells to the area, and
which open blood vessels and increase blood flow.
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
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.
and Other Triggers
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:
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
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
Infection. Infections caused by viruses or bacteria can trigger
some cases of psoriasis. Some examples include the following:
have sought a bacterial or viral agent as a cause of pustular psoriasis,
none have been identified thus far.
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.
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
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
which is used in bipolar disorder. (It may trigger the onset
of the disease and cause severe flares in people who already
a non-steroidal anti-inflammatory drug (NSAID), can cause or
worsen psoriasis (although other NSAIDs, such as meclofenamate,
may actually improve the condition).
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
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.
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.
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
SERIOUS IS PSORIASIS?
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.
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
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
About 5% of cases
fall into the moderate to severe category, which extends beyond
20% of the skin's surface.
- Mild psoriasis
affects less than 5% of the body surface. Most cases of psoriasis
are limited to less than 2% of the skin.
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
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.
psoriasis (which occurs in the folds of the skin.
and Social Consequences
Quality of Life. The emotional and social consequences of psoriasis
should not be underestimated.
have surveyed psoriasis patients on quality of life have reported
- 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
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.
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
reported that 8% of people with psoriasis felt their life was
not worth living.
Even in its mildest
form, psoriasis can still cause itching, burning, stinging, and
bleeding. These symptoms can be very debilitating in more severe
Deficiency in 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.
of Erythrodermic and Pustular Psoriasis
Regulation. Erythrodermic psoriasis, in which psoriasis covers
the entire skin, can cause abnormalities in the body's ability to
Zumbusch Psoriasis. A combination of erythrodermic and pustular
psoriasis, causes a serious condition called 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.
- The condition
can develop abruptly.
may include fever, chills, weight loss, and muscle weakness.
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.
of Psoriatic Arthritis
Most cases of
psoriatic arthritis (PsA) are mild disease, but complications can
studies indicated that patients with psoriatic arthritis had a shorter
lifespan than the general population, but more recent ones have
found no significant difference.
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.
with PsA may have a higher risk for respiratory illnesses.
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.
IS PSORIASIS DIAGNOSED?
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.
Out Other Conditions
Psoriasis Patches from Other Disorders. A number of skin conditions
resemble psoriasis. Examples include the following:
Psoriatic Arthritis from Other Conditions. Psoriatic arthritis
may resemble the following:
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.
erythroderma may be confused with drug allergic reactions, atopic
eczema, and symptoms of lymphomas.
infections, other skin conditions, or circulation problems may
also cause nail changes typical of psoriasis.
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
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.
lupus erythematosus (SLE). Symptoms of SLE may include both
a psoriasis-like rash and arthritis, which could make the diagnosis
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 causes pain, often in the fingers and toes.
ARE THE GENERAL TREATMENT GUIDELINES FOR PSORIASIS?
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.
In general, the
following three treatment options are used for psoriasis from least
to greatest potency:
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.
Medications . Options include lotions, ointments, creams,
and shampoos. These may be useful for mild-to-moderate psoriasis.
Topical medicines rarely produce complete clearance, however.
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.)
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
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
2. The transitional phase is intended to gradually introduce the
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
An example of a topical regimen that uses a single agent is as follows:
more effective, topical regimen uses the following combination for
- A high-potency
topical corticosteroid, such as halobetasol (Ultravate) used
daily until the psoriasis plaque flattens out.
that the steroid is applied only on the weekends for maintenance.
In one study,
over three quarters of patients with mild to moderate psoriasis
remained in remission with this regimen for at least six months.
- A high-potency
steroid (halobetasol) on the weekend.
- The vitamin
D3 topical agent, calcipotriene, twice daily on weekdays.
Systemic Regimens. A systemic regimen for more severe psoriasis
uses the following agents:
- The regimen
starts with cyclosporine (known as an immunosuppressant).
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
- PUVA is
added if acitretin cannot control psoriasis.
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:
is administered for about two years and stopped.
- One or
two powerful systemic drugs are then administered for one or
two years and withdrawn.
is started again and the cycle is repeated.
ARE THE TOPICAL THERAPIES FOR PSORIASIS?
are those applied only to the surface of the body. They come in
the following forms:
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.
tapes [ see Box Occlusive Tapes].
Corticosteroid topical treatments are commonly used because
of the multiple benefits, including the following:
in potency and many are available. Some are now deliverable in foam
preparations, which makes compliance much easier. They are generally
given as follows:
itching. (Sometimes itching can also be a side effect of the
drug itself, however.)
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.]
- Less potent
drugs should be used for mild to moderate psoriasis.
- High potency
for more severe conditions.
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:
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.
of the skin.
- Loss of
Some Topical Corticosteroids Used for Psoriasis
Hydrocortisone (Hytone, Penecort, Synacort, Cort-Dome, Nutracort).
Flumethasone pivalate (Locorten).
Fluocinolone acetonide (Synalar, Derma-Smoothe).
Low to medium potency
Alclometasone dipropionate (Aclovate). Hydrocortisone (Locoid,
Hydrocortisone valerate (Westcort)
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
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
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
- It irritates
the medication is life-threatening. In such cases poison control
should be called immediately.
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:
In all cases anthralin should be applied carefully. The following
are some suggestions for application:
- 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.
To apply anthralin
to the scalp, the following is recommended:
anthralin can irritate normal skin, it should not be used on
the paste is applied, affected areas are powdered with talcum
and wrapped in a dressing to protect surrounding areas.
should be washed thoroughly after use.
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.
- 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.
should be sure that the medication does not spread to the forehead
or exposed areas.
- Skin irritation
and burning. It should not be used on the face. Fair skinned
people should generally avoid it.
topical preparations do not appear to affect areas other than
the skin, people with kidney problems are advised to use anthralin
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 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.
- It appears
to help block skin cell proliferation.
- It enhances
the maturity of keratinocytes (the impaired skin cell in psoriasis).
- It has
Side Effects. They include the following:
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.
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.
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 (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 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:
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.
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.
ARE THE SYSTEMIC TREATMENTS FOR PSORIASIS?
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:
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.
drugs include hydroxyurea, sulfasalazine, and thioguanine.
agents include tacrolimus.
(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 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
- It interferes
with cell reproduction.
- It has
- It is
one of the few systemic agents proven to help patients with
complications include the following:
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
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.
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.
of blood cell production in the bone marrow.
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.
anemia from folic acid deficiencies. Supplementation with folic
acid while taking methotrexate can prevent this side effect.
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.
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.
(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:
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:
- They have
- They help
regulate cell reproduction.
- They may
even improve arthritis that accompanies psoriasis.
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:
doses should be as low as possible and should be taken every
second or third day.
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 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
- The drugs
may cause eye problems, including blurred vision, cataracts,
and a sudden deterioration in night vision.
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
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 (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:
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.
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
- It increases
the risk for unhealthy cholesterol and lipid levels.
use always causes some kidney damage.
- It causes
abnormalities in the liver.
it suppresses the immune system, cyclosporine also increases
the risk for infections.
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
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.
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
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
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.
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
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.
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
ARE THE PHOTOTHERAPY TREATMENTS FOR PSORIASIS?
Recommendations for Phototherapy
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
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.
- UVB is
the primary agent in sunburning and primarily affects the outer
- UVA penetrates
more deeply and efficiently.
Although both UVA and UVB can destroy psoriasis skin cells when
used in phototherapies, there are some differences:
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.
- 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
People Who Should Avoid Phototherapy. T he following patients
should avoid phototherapy.
with very severe psoriasis.
who are sensitive to sunlight.
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
Ultraviolet B (UVB) Radiation
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
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
UVB radiation alone.
- UVB treatment
with coal tar (the Goeckerman regimen).
- UVB with
anthralin (the Ingram regimen).
Broadband UVB Procedures Used Without Medication. When used
without medication (known as selective ultraviolet phototherapy)
UVB treatment generally is administered as follows:
UVB Procedures Used With Medication. When combined with coal
tar or anthralin, UVB may be administered as follows:
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
- Full results
take about three weeks.
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.
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
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.
may need to be administered daily for two to four weeks.
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.
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:
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.
times are shorter but of higher intensity than with broadband
- 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.
One expert suggests the following treatment schedule:
are performed three times a week to start.
of 75% typically occurs after 10 to 12 treatments.
maintenance treatments are given once a week.
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
and Ultraviolet A Radiation (PUVA)
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:
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.]
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.)
and redness in the skin develop within two to three days after
- Such damage
inhibits skin cell proliferation.
Initial PUVA Treatment Phase. The initial phase typically
follows these steps:
It takes an average
of about 30 treatments for full effect, but during that period,
treatment intensity may vary:
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.)
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.
Phase. Once the psoriasis has improved by about 95%, the patient
is put on a maintenance schedule:
- 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
of PUVA. Adverse side effects include the following:
- The patient
starts with weekly treatments.
- They gradually
become less frequent until they are administered only for flare
- 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.
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.
- 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.
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.
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
Even more worrisome
was a study reporting an increased risk in melanoma, a very serious
who have had over 200 treatments.
with a family or personal history of skin cancer.
with light skin and fair or red hair.
who have had radiation or x-ray treatments or taken immunosuppressant
Discussions are underway, in fact, about discontinuing PUVA for
[ See also
Report #32, Melanoma.]
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.
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.
Protective Measures with PUVA Therapy
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:
safety features should be available in the PUVA chamber:
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.)
Measures After Treatment. The patient should take the
following precautions after treatment:
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
A timer that terminates the session automatically.
An accessible alarm device.
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
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.
ARE DIETARY AND OTHER LIFESTYLE FACTORS FOR MANAGING PSORIASIS?
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.
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.
reported that patients treated with antidepressants along with
topical corticosteroids for psoriasis experienced greater skin
improvement than those who took the steroid alone.
aimed at reducing stress may improve symptoms, according to
a small 1999 study.
If skin becomes
dry and itchy, the patient may try the following:
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.
- Soak in
a warm bath for about 15 minutes.
apply salicylic acid first, which removes scaly skin and may
promote the penetration of both moisturizers and topical prescription
apply a thick moisturizer or emollient, such as Vaseline, Cetaphil
cream, or Eucerin cream. (Lotions are not adequate moisturizers.)
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.
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
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:
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
- 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.
(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.
reports also suggest that some patients may benefit from taking
garlic capsules. There is no scientific evidence for such benefits.
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.
Warnings on Alternative and So-Called Natural Remedies
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.
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).
ELSE CAN PEOPLE WITH PSORIASIS GET HELP?
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
930 N. Meacham Rd., Schaumburg, IL 60168-4014.
Call (847-330-0230) or (888-462-3376) or (https://www.aad.org/)
The website specifically for psoriasis.
ead Sea Psoriasis
& Arthritis Treatment Foundation
Psoriasis Genetics Laboratory at the University of Michigan. This
contains information about genetic research and psoriasis. On
Clinical Trial Sites