Psoriasis medical therapy: Difference between revisions
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*** Alternative regimen (5): [[Topical]] [[pimecrolimus]] 0.1% [[Cream (pharmaceutical)|cream]] q 12 hours for 8 weeks | *** Alternative regimen (5): [[Topical]] [[pimecrolimus]] 0.1% [[Cream (pharmaceutical)|cream]] q 12 hours for 8 weeks | ||
*** Alternative regimen (6): [[Topical]] [[tacrolimus]] 0.1% [[ointment]] q 12 hours for 8 weeks | *** Alternative regimen (6): [[Topical]] [[tacrolimus]] 0.1% [[ointment]] q 12 hours for 8 weeks | ||
* 2 '''Severe psoriasis''' | |||
** 2.1 '''Adults''' | |||
*** Preferred regimen (1): [[Topical]] and [[UVB radiation|UVB]] [[phototherapy]] plus [[systemic]] PO [[methotrexate]] for 2-4 weeks | *** Preferred regimen (1): [[Topical]] and [[UVB radiation|UVB]] [[phototherapy]] plus [[systemic]] PO [[methotrexate]] for 2-4 weeks | ||
*** Alternative regimen (1): [[Topical]] [[UVB radiation|UVB]] [[phototherapy]] plus [[systemic]] PO [[cyclosporine]] for 2-4 weeks | *** Alternative regimen (1): [[Topical]] [[UVB radiation|UVB]] [[phototherapy]] plus [[systemic]] PO [[cyclosporine]] for 2-4 weeks | ||
| Line 205: | Line 205: | ||
*** Alternative regimen (7): [[Topical]] [[UVB]] [[phototherapy]] plus SC [[etanercept]] 50 mg twice per week for 3 months | *** Alternative regimen (7): [[Topical]] [[UVB]] [[phototherapy]] plus SC [[etanercept]] 50 mg twice per week for 3 months | ||
*** Alternative regimen (8): [[Topical]] [[UVB radiation|UVB]] [[phototherapy]] plus IV [[infliximab]] 5 mg per kg dose infusion schedule at week 0, 2, and 6 and then every 6-8 weeks for 3 months | *** Alternative regimen (8): [[Topical]] [[UVB radiation|UVB]] [[phototherapy]] plus IV [[infliximab]] 5 mg per kg dose infusion schedule at week 0, 2, and 6 and then every 6-8 weeks for 3 months | ||
=== Treatment of psoriasis according to disease sub-type === | |||
Treatment of various sub-types of psoriasis includes the following: | |||
* 1 '''Localized pustular psoriasis''' | |||
** 1.1 '''Adults''' | |||
*** Preferred regimen (1): [[Topical]] [[clobetasol propionate]] plus topical bath psoralen plus UVA phototherapy ([[PUVA therapy|PUVA]]) for 3 weeks | |||
*** Alternative regimen (2): [[Topical]] [[clobetasol propionate]] plus PO acitretin 25-40 mg q 24 hours for 3 weeks | |||
* 2 '''Nail psoriasis''' | |||
** 2.1 '''Adults''' | |||
*** Preferred regimen (1): [[Topical]] [[clobetasol propionate]] q 24 hours for 2-4 weeks | |||
*** Preferred regimen (2): [[Topical]] [[calcipotriene]] ointment q 12 hours for 2-4 weeks | |||
* 3 '''Erythrodermic psoriasis''' | |||
** 3.1 '''Adults''' | |||
*** Preferred regimen (1): SC [[etanercept]] 50 mg twice per week for 3 months | |||
*** Preferred regimen (2): SC [[adalimumab]] 80 mg the first week, 40 mg the second wk, followed by 40 mg every other week | |||
*** Preferred regimen (3): SC [[ustekinumab]] 45 mg at 0 and 4 weeks, and then every 12 weeks thereafter | |||
=== Treatment of psoriatic arthritis === | === Treatment of psoriatic arthritis === | ||
Revision as of 11:52, 23 August 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]
Overview
The mainstay of therapy for psoriasis consists of the application of topical agents directly onto the lesions. Topical agents include corticosteroids, vitamin D analogues, tar, anthralin, tazarotene, calcineurin inhibitors, and aloe vera extracts. Systemic therapy may also be used, including immunosupressants to counteract the progression of the disease.
Medical Therapy
Therapies are administered according to disease severity as assessed by the Psoriasis Area and Severity Index (PASI, ranging from 0 to 72), which takes into account appearance and extension of the lesions. Interventions in medical therapy for psoriasis include:
- Topical therapy
- Phototherapy
- Systemic therapy (immunosuppressive agents and biological therapy)
Topical therapy
- Medicated creams and ointments applied directly to psoriatic lesions can help decrease inflammation, remove built-up scale, reduce skin turnover, and clear affected skin of plaques.[1]
- Approved drugs that can be used as topical therapy for acute management of psoriasis include:[2][3][4][5][6]
- Corticosteroids
- Vitamin D analogues (calcipotriol)
- Tar
- Dithranol (anthralin)
- Tazarotene (a retinoid)
- Calcineurin inhibitors (tacrolimus and primecrolimus are used specially for flexural or facial psoriasis)
- Aloe vera extract 0.5% hydrophilic cream
- Anti-IL-8 monoclonal antibody cream
- Betamethasone 17-valerate 21-acetate plus tretinoin plus salicylic acid
- Fish oil plus occlussion
- Combination of nicotinamide and calcipotriene
- Combined treatment with vitamin D/corticosteroid on either the body or the scalp generates significantly better outcomes than vitamin D alone.[7]
- The disadvantages of topical agents are that they can often irritate normal skin, can be time consuming and awkward to apply, cannot be used for long periods, can stain clothing, and can have a strong odor. As a result, it is sometimes difficult for people to maintain the regular application of these medications.
- Abrupt withdrawal from the use of some topical agents, particularly corticosteroids, can cause an aggressive recurrence of the condition.
- Some topical agents are commonly used in conjunction with other therapies, especially phototherapy.
Phototherapy
- It has long been recognized that daily, short, non-burning exposure to sunlight can help clear or improve psoriasis.[8]
- Niels Finsen was the first physician to investigate the therapeutic effects of sunlight scientifically and to use sunlight in clinical practice. This became known as phototherapy.
- The narrow band part of the UVB spectrum (311 to 312 nm) is most helpful for the management of psoriasis. Exposure to UVB several times per week over several weeks can facilitate remission from psoriasis.
- Ultraviolet light treatment is frequently combined with topical (coal tar, calcipotriol) or systemic treatment (retinoids).
- The Ingram regime involves UVB and the application of anthralin paste.
- The Goeckerman regime combines coal tar ointment with UVB.
Systemic therapy
The following drugs may be used in the treatment of psoriasis:[9][10][11][12][13]
| Type of agent | Mechanism of action | Name | Molecular target | Formulation | Administration route |
|---|---|---|---|---|---|
| Biologic | Anti-metabolite | Methotrexate | DHFR | NA | Oral or IV |
| Anti-T cell | Cyclosporine | Cyclophilin | NA | Oral or IV | |
| Alefacept | CD2 | Human LFA-3/IgG1 fusion protein | IM or IV | ||
| Efalizumab | CD11a | Humanized IgG1 monoclonal antibody | SC | ||
| Abatacept | CTLA-4 | Human CTLA4–Ig-IgG1 fusion protein | SC or IV | ||
| Anticytokine | Etanercept | TNF | Human TNF-R (p75)-lgG1 fusion protein | SC | |
| Infliximab | TNF | Mouse-human IgG1 chimeric monoclonal antibody | IV | ||
| Adalimumab | TNF | Human IgG1 monoclonal antibody | SC | ||
| Ustekinumab | IL-2, IL-23 | Human IgG1 monoclonal antibody | SC | ||
| Briakinumab (discontinued in USA in 2011) | IL-12, IL-23 | Human IgG1 monoclonal antibody | SC | ||
| Guselkumab | IL-23p19 | Human IgG1 monoclonal antibody | SC | ||
| Brodalumab | IL-17R | Human IgG2 monoclonal antibody | SC | ||
| Ixekizumab | IL-17 | Humanized IgG4 monoclonal antibody | SC | ||
| Secukinumab | IL-17 | Human IgG1 monoclonal antibody | SC or IV | ||
| Fezakinumab | IL-22 | Human IgG1 monoclonal antibody | SC or IV | ||
| Small molecule | PDE4 inhibitor | Apremilast | PDE4 | NA | Oral |
| JAK inhibitor | Tofacitinib | JAK1 and JAK3 | NA | Oral | |
| Baricitinib | JAK1 and JAK2 | NA | Oral | ||
| PKC inhibitor | AEB071 | PKC | NA | Oral | |
| A3AR agonist | CF101 | A3AR | NA | Oral |
DHFR: Dihydrofolate reductase
SC: Sub-cutaneous
IV: Intra-venous
IM: Intra-muscular
NA: Not Applicable
PDE4: Phosphodiesterase 4
JAK: Janus Kinase
PKC: Protein Kinase C
LFA: Lymphocyte function associated antigen
TNF: Tumor necrosis factor
Treatment of psoriasis according to severity
The American Academy of Dermatology has published guidelines for the treatment of psoriasis. The guidelines are as follows:[14]
- 1 Mild-moderate psoriasis
- 1.1 Adults
- Preferred regimen (1): Topical betamethasone plus calcipotriene q 12 hours for 1 week
- Preferred regimen (2): Topical clobetasol propionate plus tazarotene q 12 hours for 2-4 weeks
- Alternative regimen (1): Topical clobetasol propionate plus calcipotriene ointment q 12 hours for 2-4 weeks
- Alternative regimen (2):Topical clobetasol propionate plus calcitriol ointment topical 3 mcg per g q 12 hours for 2-4 weeks
- Alternative regimen (3): Topical clobetasol propionate plus tar q 12 hours for 2-4 weeks
- Alternative regimen (4): Localized phototherapy 500-900 mJ per cm2 2-3 times per week for 10 weeks
- Alternative regimen (5): Topical pimecrolimus 0.1% cream q 12 hours for 8 weeks
- Alternative regimen (6): Topical tacrolimus 0.1% ointment q 12 hours for 8 weeks
- 1.1 Adults
- 2 Severe psoriasis
- 2.1 Adults
- Preferred regimen (1): Topical and UVB phototherapy plus systemic PO methotrexate for 2-4 weeks
- Alternative regimen (1): Topical UVB phototherapy plus systemic PO cyclosporine for 2-4 weeks
- Alternative regimen (2): Topical UVB phototherapy plus systemic PO tazarotene for 2-4 weeks
- Alternative regimen (3): Topical UVB phototherapy plus PUVA therapy (PO 8-methoxypsoralen 0.4-0.6 mg per kg given 1.5 hours before exposure to UVA) for 2-4 weeks
- Alternative regimen (4): Topical UVB phototherapy plus IM alefacept 15 mg per week for 12 weeks
- Alternative regimen (5): Topical UVB phototherapy plus SC efalizumab 0.7 mg per kg first dose followed by 1.0 mg per kg per week for 3 months
- Alternative regimen (6): Topical UVB phototherapy plus SC adalimumab 80 mg the first week, 40 mg the second wk, followed by 40 mg every other week
- Alternative regimen (7): Topical UVB phototherapy plus SC etanercept 50 mg twice per week for 3 months
- Alternative regimen (8): Topical UVB phototherapy plus IV infliximab 5 mg per kg dose infusion schedule at week 0, 2, and 6 and then every 6-8 weeks for 3 months
- 2.1 Adults
Treatment of psoriasis according to disease sub-type
Treatment of various sub-types of psoriasis includes the following:
- 1 Localized pustular psoriasis
- 1.1 Adults
- Preferred regimen (1): Topical clobetasol propionate plus topical bath psoralen plus UVA phototherapy (PUVA) for 3 weeks
- Alternative regimen (2): Topical clobetasol propionate plus PO acitretin 25-40 mg q 24 hours for 3 weeks
- 1.1 Adults
- 2 Nail psoriasis
- 2.1 Adults
- Preferred regimen (1): Topical clobetasol propionate q 24 hours for 2-4 weeks
- Preferred regimen (2): Topical calcipotriene ointment q 12 hours for 2-4 weeks
- 2.1 Adults
- 3 Erythrodermic psoriasis
- 3.1 Adults
- Preferred regimen (1): SC etanercept 50 mg twice per week for 3 months
- Preferred regimen (2): SC adalimumab 80 mg the first week, 40 mg the second wk, followed by 40 mg every other week
- Preferred regimen (3): SC ustekinumab 45 mg at 0 and 4 weeks, and then every 12 weeks thereafter
- 3.1 Adults
Treatment of psoriatic arthritis
The following drugs may be used in the treatment of psoriatic arthritis:[15]
| Drug | Mechanism | Comments |
|---|---|---|
| NSAIDs |
| |
| Corticosteroids | ||
| Sulfasalazine |
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| Methotrexate |
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| Cyclosporine |
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| Leflunomide |
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| Etanercept |
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| Infliximab |
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| Adalimumab |
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| Alefacept |
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| Efalizumab |
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| Abatacept |
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References
- ↑ Smith CH, Barker JN (2006). "Psoriasis and its management". BMJ. 333 (7564): 380–4. doi:10.1136/bmj.333.7564.380. PMC 1550454. PMID 16916825.
- ↑ Ashcroft DM, Po AL, Williams HC, Griffiths CE (2000). "Systematic review of comparative efficacy and tolerability of calcipotriol in treating chronic plaque psoriasis". BMJ. 320 (7240): 963–7. PMC 27334. PMID 10753146.
- ↑ Syed TA, Ahmad SA, Holt AH, Ahmad SA, Ahmad SH, Afzal M (1996). "Management of psoriasis with Aloe vera extract in a hydrophilic cream: a placebo-controlled, double-blind study". Trop. Med. Int. Health. 1 (4): 505–9. PMID 8765459.
- ↑ Naldi L, Rzany B (2009). "Psoriasis (chronic plaque)". BMJ Clin Evid. 2009. PMC 2907770. PMID 19445765.
- ↑ Escobar SO, Achenbach R, Iannantuono R, Torem V (1992). "Topical fish oil in psoriasis--a controlled and blind study". Clin. Exp. Dermatol. 17 (3): 159–62. PMID 1451289.
- ↑ Levine D, Even-Chen Z, Lipets I, Pritulo OA, Svyatenko TV, Andrashko Y, Lebwohl M, Gottlieb A (2010). "Pilot, multicenter, double-blind, randomized placebo-controlled bilateral comparative study of a combination of calcipotriene and nicotinamide for the treatment of psoriasis". J. Am. Acad. Dermatol. 63 (5): 775–81. doi:10.1016/j.jaad.2009.10.016. PMID 20599292.
- ↑ "Topical treatments for chronic plaque psoriasis - Mason - 2013 - The Cochrane Library - Wiley Online Library".
- ↑ Naldi L, Rzany B (2009). "Psoriasis (chronic plaque)". BMJ Clin Evid. 2009. PMC 2907770. PMID 19445765.
- ↑ Rosmarin DM, Lebwohl M, Elewski BE, Gottlieb AB (2010). "Cyclosporine and psoriasis: 2008 National Psoriasis Foundation Consensus Conference". J. Am. Acad. Dermatol. 62 (5): 838–53. doi:10.1016/j.jaad.2009.05.017. PMID 19932926.
- ↑ Schmitt J, Rosumeck S, Thomaschewski G, Sporbeck B, Haufe E, Nast A (2014). "Efficacy and safety of systemic treatments for moderate-to-severe psoriasis: meta-analysis of randomized controlled trials". Br. J. Dermatol. 170 (2): 274–303. doi:10.1111/bjd.12663. PMID 24131260.
- ↑ Nowicki B, Holthöfer H, Saraneva T, Rhen M, Väisänen-Rhen V, Korhonen TK (1986). "Location of adhesion sites for P-fimbriated and for 075X-positive Escherichia coli in the human kidney". Microb. Pathog. 1 (2): 169–80. PMID 2907770.
- ↑ Hsu S, Papp KA, Lebwohl MG, Bagel J, Blauvelt A, Duffin KC, Crowley J, Eichenfield LF, Feldman SR, Fiorentino DF, Gelfand JM, Gottlieb AB, Jacobsen C, Kalb RE, Kavanaugh A, Korman NJ, Krueger GG, Michelon MA, Morison W, Ritchlin CT, Stein Gold L, Stone SP, Strober BE, Van Voorhees AS, Weiss SC, Wanat K, Bebo BF (2012). "Consensus guidelines for the management of plaque psoriasis". Arch Dermatol. 148 (1): 95–102. doi:10.1001/archdermatol.2011.1410. PMID 22250239.
- ↑ Menter A, Gottlieb A, Feldman SR, Van Voorhees AS, Leonardi CL, Gordon KB, Lebwohl M, Koo JY, Elmets CA, Korman NJ, Beutner KR, Bhushan R (2008). "Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics". J. Am. Acad. Dermatol. 58 (5): 826–50. doi:10.1016/j.jaad.2008.02.039. PMID 18423260.
- ↑ "Psoriasis: Recommendations for broadband and narrowband UVB therapy | American Academy of Dermatology".
- ↑ Day MS, Nam D, Goodman S, Su EP, Figgie M (2012). "Psoriatic arthritis". J Am Acad Orthop Surg. 20 (1): 28–37. doi:10.5435/JAAOS-20-01-028. PMID 22207516.