Psoriasis medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
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Revision as of 18:36, 10 April 2013
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Psoriasis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Psoriasis medical therapy On the Web |
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American Roentgen Ray Society Images of Psoriasis medical therapy |
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Risk calculators and risk factors for Psoriasis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Medical Therapy
There can be substantial variation between individuals in the effectiveness of specific psoriasis treatments. Because of this, dermatologists often use a trial-and-error approach to finding the most appropriate treatment for their patient. The decision to employ a particular treatment is based on the type of psoriasis, its location, extent and severity. The patient’s age, sex, quality of life, comorbidities, and attitude toward risks associated with the treatment are also taken into consideration.
In 2008, the FDA approved three new treatment options[1] available to psoriasis patients:
- Taclonex Scalp, a new topical ointment for treating scalp psoriasis;
- The Xtrac Velocity excimer laser system, which emits a high-intensity beam of ultraviolet light, can treat moderate to severe psoriasis
- The biologic drug adalimumab (brand name Humira) was also approved to treat moderate to severe psoriasis. Adalimumab had already been approved to treat psoriatic arthritis.
Medications with the least potential for adverse reactions are preferentially employed. If the treatment goal is not achieved then therapies with greater potential toxicity may be used. Medications with significant toxicity are reserved for severe unresponsive psoriasis. This is called the psoriasis treatment ladder.[2] As a first step, medicated ointments or creams, called topical treatments, are applied to the skin. If topical treatment fails to achieve the desired goal then the next step would be to expose the skin to ultraviolet (UV) radiation. This type of treatment is called phototherapy. The third step involves the use of medications which are taken internally by pill or injection. This approach is called systemic treatment.
Over time, psoriasis can become resistant to a specific therapy. Treatments may be periodically changed to prevent resistance developing (tachyphylaxis) and to reduce the chance of adverse reactions occurring. This is called treatment rotation.
Antibiotics are generally not indicated in routine treatment of psoriasis. However, antibiotics may be employed when an infection, such as that caused by the bacteria Streptococcus, triggers an outbreak of psoriasis, as in certain cases of guttate psoriasis.
A psychological symptom management programme has been reported as being a helpful adjunct to traditional therapies in the management of psoriasis.[3]
Pharmacotherapy
Acute Pharmacotherapies
Topical treatment
Bath solutions and moisturizers help sooth affected skin and reduce the dryness which accompanies the build-up of skin on psoriatic plaques. Medicated creams and ointments applied directly to psoriatic plaques can help reduce inflammation, remove built-up scale, reduce skin turn over, and clear affected skin of plaques. Ointment and creams containing coal tar (no longer available on prescription in the UK), dithranol (anthralin), corticosteroids, vitamin D3 analogues (for example, calcipotriol), and retinoids are routinely used. The mechanism of action of each is probably different but they all help to normalise skin cell production and reduce inflammation. Activated vitamin D and its analogues are highly effective inhibitors of skin cell proliferation.
The disadvantages of topical agents are variably that they can often irritate normal skin, can be time consuming and awkward to apply, cannot be used for long periods, can stain clothing or have a strong odour. As a result, it is sometimes difficult for people to maintain the regular application of these medications. Abrupt withdrawal of some topical agents, particularly corticosteroids, can cause an aggressive recurrence of the condition. This is known as a rebound of the condition.
Some topical agents are used in conjunction with other therapies, especially phototherapy.
Chronic Pharmacotherapies
Systemic treatment
Psoriasis which is resistant to topical treatment and phototherapy is treated by medications that are taken internally by pill or injection. This is called systemic treatment. Patients undergoing systemic treatment are required to have regular blood and liver function tests because of the toxicity of the medication. Pregnancy must be avoided for the majority of these treatments. Most people experience a recurrence of psoriasis after systemic treatment is discontinued.
The three main traditional systemic treatments are the immunosupressant drugs methotrexate and cyclosporine, and retinoids, which are synthetic forms of vitamin A. Other additional drugs, not specifically licensed for psoriasis, have been found to be effective. These include the antimetabolite tioguanine, the cytotoxic agent hydroxyurea, sulfasalazine, the immunosupressants mycophenolate mofetil, azathioprine and oral tacrolimus. These have all been used effectively to treat psoriasis when other treatments have failed. Although not licensed in many other countries fumaric acid esters have also been used to treat severe psoriasis in Germany for over 20 years.
Biologics are manufactured proteins that interrupt the immune process involved in psoriasis. Unlike generalised immunosuppressant therapies such as methotrexate, biologics focus on specific aspects of the immune function leading to psoriasis. These drugs (interleukin antagonists) are relatively new, and their long-term impact on immune function is unknown. They are very expensive and only suitable for very few patients with psoriasis. Ustekinumab (IL-12 and IL-23 blocker) shows hopeful results for psoriasis therapy.
Phototherapy
It has long been recognized that daily, short, non-burning exposure to sunlight helped to clear or improve psoriasis. 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.
Sunlight contains many different wavelengths of light. It was during the early part of the 20th century that it was recognised that for psoriasis the therapeutic property of sunlight was due to the wavelengths classified as ultraviolet (UV) light.
Ultraviolet wavelengths are subdivided into UVA (380–315 nm) UVB (315–280 nm), and UVC (< 280 nm). Ultraviolet B (UVB) (315–280 nm) is absorbed by the epidermis and has a beneficial effect on psoriasis. Narrowband UVB (311 to 312 nm), is that part of the UVB spectrum that is most helpful for psoriasis. Exposure to UVB several times per week, over several weeks can help people attain a remission from psoriasis.
Ultraviolet light treatment is frequently combined with topical (coal tar, calcipotriol) or systemic treatment (retinoids) as there is a synergy in their combination. The Ingram regime, involves UVB and the application of anthralin paste. The Goeckerman regime combines coal tar ointment with UVB.
Photochemotherapy
Psoralen and ultraviolet A phototherapy (PUVA) combines the oral or topical administration of psoralen with exposure to ultraviolet A (UVA) light. Precisely how PUVA works is not known. The mechanism of action probably involves activation of psoralen by UVA light which inhibits the abnormally rapid production of the cells in psoriatic skin. There are multiple mechanisms of action associated with PUVA, including effects on the skin immune system.
Dark glasses must be worn during PUVA treatment because there is a risk of cataracts developing from exposure to ultraviolet A light. PUVA is associated with nausea, headache, fatigue, burning, and itching. Long-term treatment is associated with squamous-cell and melanoma skin cancers.
Alternative therapy
- Antibiotics are not indicated in routine treatment of psoriasis. However, antibiotics may be employed when an infection, such as that caused by the bacteria Streptococcus, triggers an outbreak of psoriasis, as in certain cases of guttate psoriasis.
- Climatotherapy involves the notion that some diseases can be successfully treated by living in particular climate. Several psoriasis clinics are located throughout the world based on this idea. The Dead Sea is one of the most popular locations for this type of treatment.
- In Turkey & in Croatia (Altermedica), doctor fish which live in the outdoor pools of spas, are encouraged to feed on the psoriatic skin of people with psoriasis. The fish only consume the affected areas of the skin. The outdoor location of the spa may also have a beneficial effect. This treatment can provide temporary relief of symptoms. A revisit to the spas every few months is often required. Best known is the spa “Kangal Thermal Springs”, near the Turkish village of Kavak. According to the testimony of numerous psoriasis patients, the fish lead to a significant relief. This spa is located south of the historic silk road in Anatolia. The next big city is Sivas. Treatment in this hot spring has been examined until now in two small clinical trials, with positive results.[4] [5]
- Some people subscribe to the view that psoriasis can be effectively managed through a healthy lifestyle. This view is based on anecdote, and has not been subjected to formal scientific evaluation. Nevertheless, some people report that minimizing stress and consuming a healthy diet, combined with rest, sunshine and swimming in saltwater keep lesions to a minimum. This type of "lifestyle" treatment is suggested as a long-term management strategy, rather than an initial treatment of severe psoriasis.
- A number of patients have reported significant improvements from sun and sea water: unfortunately, salt alone does not have any effect. Sea water contains so many minerals and different life forms (thousands of species of bacteria alone[6]) that it will be hard to determine which of these is causing the observed effects. Interestingly, people in the tropics differentiate between "live" and "dead" sea water: "live" sea water is water that has never been covered.
- Some psoriasis patients use herbology as a holistic approach that aims to treat the underlying causes of psoriasis. Some alternative therapies consider Oil of Oregano to be a powerful herbal method of treatment.
- A psychological symptom management programme has been reported as being a helpful adjunct to traditional therapies in the management of psoriasis.[7]
- It is claimed that Epsom salt may have a positive effect in reducing the effects of psoriasis.(The Home Remedies Handbook)
- There are claims that Neem oil has been in documented use in India for 6000 years. There are claims that this documentation is fraudulent.[8]
- It is claimed that yoga and meditative practices help psoriasis patients by 'detoxifying' the body and by the reduction of stress.
- Sulphur has been used for many years as a safe treatment in the alleviation of Psoriasis.
- Fasting is used by some to treat mild forms of psoriasis.
References
- ↑ "Psoriasis Medical Breakthroughs" Parade.com
- ↑ Lofholm PW (2000). "The psoriasis treatment ladder: a clinical overview for pharmacists". US Pharm. 25 (5): 26–47.
- ↑ "Research Findings Register: summary number 637". Retrieved 2007-07-22.
- ↑ Ozcelik S, Polat HH, Akyol M, Yalcin AN, Ozcelik D, Marufihah M. Kangal hot spring with fish and psoriasis treatment. J Dermatol. 2000 Jun;27(6):386-90.
- ↑ Grassberger M, Hoch W. Ichthyotherapy as alternative treatment for patients with psoriasis: a pilot study. Evid Based Complement Alternat Med. 2006 Dec;3(4):483-8.
- ↑ "News in Science - Oceans a complex, diverse bug soup - 01/08/2006". Retrieved 2007-07-22.
- ↑ "Research Findings Register: summary number 637". Retrieved 2007-07-22.
- ↑ "Psoriasis Hall of PShame". Retrieved 2007-07-22.