Psoriasis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
Therapies are administered according to disease severity and 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 comprise of:
- Topical therapy
- Phototherapy
- Systemic therapy (Immunosuppressive agents and biological therapy)
Topical therapy[1]
- Medicated creams and ointments applied directly to psoriatic lesions can help decrease inflammation, remove built-up scale, reduce skin turn over, and clear affected skin of plaques.
- Approved drugs that can be used as topical therapy for acute management of psoriasis include:
- Corticosteroids
- Vitamin D analogues (calcipotriol)[2]
- Tar
- Dithranol (anthralin)
- Tazarotene (a retinoid)
- Calcineurin inhibitors (Tacrolimus and primecrolimus- used specially foe flexural or facial psoriasis)
- Aloe vera extract 0.5 % hydrophilic cream[3]
- Anti-IL-8 monoclonal antibody cream
- Betamethasone 17-valerate 21-acetate plus tretinoin plus salicylic acid[4]
- Fish oil plus occlussion[5]
- Combination of nicotinamide and calcipotriene[6]
- Combined treatment with vitamin D/corticosteroid on either the body or the scalp has significantly better outcomes than vitamin D alone.[7]
- 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.
- Some topical agents are used in conjunction with other therapies, especially phototherapy.
Phototherapy[8]
- 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.
- Narrow band part of the UVB spectrum (311 to 312 nm) 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.
Systemic therapy[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-12p40 (IL-2, IL-23) | Human IgG1 monoclonal antibody | SC | ||
| Briakinumab (discontinued in USA in 2011) | IL-12p40 (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
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.