Psoriasis Treatment Options (Topical, Light & Systemic Therapies)

Conditions & Diseases: Skin Diseases

Psoriasis

Psoriasis Treatment Options

Like many skin diseases, there is no cure for psoriasis. An array of treatment options do exist and patients will have to consider them under a long-term treatment plan. Treatment plans will vary according to age, sex, type of psoriasis, location of the plaques and severity of the plaques. According to Dr. Hon Pak reporting for EmedicineHealth.com, treatment may also depend on the patient's perception and acceptance of their psoriasis. "Treatment must be designed with the patient's specific expectations in mind, rather than focusing on the extent of body surface area involved." (5)

Treatment of Psoriasis generally follows a 3-step approach involving:

Topical Therapy (applied directly to the skin)
Light Therapy (treatments where skin is exposed to ultraviolet light)
Systemic Therapy (drugs or medications taken orally or by injection).

For patients with a minimal amount of psoriasis, topical therapy may be enough. Other patients may need a combination of the three. There is no one way to treat psoriasis as patients may respond differently to different medications. Treatment plans may also have to be periodically changed and mixed up to counter against your body developing a resistance to certain medications.

"Over time, affected skin can become resistant to treatment, especially when topical corticosteroids are used. Also, a treatment that works very well in one person may have little effect in another. Thus, doctors often use a trial-and-error approach to find a treatment that works, and they may switch treatments periodically (for example, every 12 to 24 months) if a treatment does not work or if adverse reactions occur." (2)

1. Topical Therapy
The first line of defense in treating psoriasis begins with topical therapy. Topical treatments can soothe the itching and irritation, reduce inflammation as well as slow down the excessive cell growth the causes plaques to grow. Some topical treatments, such as bath and lotion moisturizers are only meant to soothe the associated symptoms (itching and dryness) and do little to treat the disease. The most common medicated creams and ointments are listed below.

Topical Steroids (Corticosteroids): Corticosteroids, or just "steroids," are the most frequently used topical treatment options for psoriasis since they work fast, are easy to use, and are effective at reducing inflammation and swelling. In mild cases of psoriasis, topical steroids can be quite effective, but in cases of moderate to severe psoriasis, topical steroids will have to be used in combination with other therapies. There are many different brands and potency levels of corticosteroids, each of which have side-effects including thinning of the skin. Follow your doctor's guidelines when using corticosteroids.
Clobetasol Propionate: Is a high potency corticosteroid which is topically applied as an ointment for eczema and psoriasis. When sold under the brand name, Olux, it is dispensed as a foam, which penetrates the skin and can make it less messy. It is effective in treating psoriasis of the scalp and body.
Calcipotriene (Vitamin D3 derivative, brand name Dovonex, Taclonex): Calcipotriene is a synthetic form of a Vitamin D3 and is often prescribed under the brand name Dovonex which has been approved by the FDA for treating psoriasis. Dovonex "...slows down the rate of skin cell growth, flattens psoriasis lesions and removes scale. It is not effective at decreasing inflammation, though for most patients redness will improve over time."(1) Dovenex has proved effective in treating nail psoriasis and a special version exists for treatment of scalp psoriasis. Dovonex has been an attractive option for the treatment of psoriasis due it's lack of severe side-effects. The NPF also reports that using Dovonex in combination with topical steroids may be more effective then using Dovonex alone. This combination includes applying topical steroids in the morning, and dovonex at night. Dovonex works well with phototherapy treatments, but should not be used in conjunction with salicylic acid which can render Dovonex ingredients inactive. Since many doctors prescribe Dovonex in conjunction with a steroid, a new medication, called Taclonex, was created which combines the active ingredient in Dovonexd (calcipotriene) with a potent steroid called betamethasone dipropionate. Taclonex is FDA approved for psoriasis. Follow your doctor's guidelines and the instructions which accompany the prescription.(1)
Topical Retinoids (brand name Tazorac): Retinoids are a synthetic form of vitamin A and are often prescribed under the brand name Tazorac, for which retinoid is the main ingredient. Tazorac can be used on the face, scalp and nails. Results with Tazorec may be seen in 2 to 12 weeks. Retinoids should not be used by pregnant women. Follow your doctor's guidelines and the instructions which accompany the prescription.
Anthralin (also called Dithranol): Anthralin is a synthetic substitute of chrysarobin, a substance found in the bark of a South American tree and used a treatment for psoriasis for over 100 years. Anthralin works by reducing the rapid growth of skin cells which cause plaques to develop. Doctors usually prescribe anthralin to be applied for short periods of 10 to 30 minutes and then removed or washed off completely. Anthralin may take several weeks of application before positive results can be seen and can also be messy. Although it is not as strong as topical steroids, anthralin has no long-term side-effects.
Coal Tar: Coal tar is derived from the coal carbonization process and is a popular and frequently used topical treatment for many types of skin conditions. In patients with psoriasis, coal tar can reduce inflammation, reduce rapid skin cell growth which causes plaques to form, relieve itching and irritation, and improve the skin's appearance. Coal tar is available over the counter (OTC) in shampoo, gel and cream form. Coal tar can be messy. Follow your doctor's guidelines and/or the instructions that accompany the product when you purchase it.
Salicylic Acid: Salicylic acid helps remove and reduce the scales that accompany plaque psoriasis. It is often used in combination with other topical treatments such as steroids, tar, and anthralin, or can be mixed together by the pharmacist (with a doctor's prescription) with other ingredients. Salicylic acid comes in many OTC topical forms: cream, gel, lotion, ointment, pads, plaster, shampoo, soap and solution. The 3 percent and under solution is available OTC and solutions over 3 percent require a doctor's prescription.

Light Therapy (also called Phototherapy):
Ultraviolet light from the Sun has been proven to slow the production of skin cell growth and reduce inflammation. "When absorbed into the skin, UV light suppresses the process leading to disease, causing activated T cells in the skin to die." (2)

Although too much Sun can be harmful for some psoriasis patients, light treatments administered with special phototherapy equipment, either in a doctor's office or using a home-based unit, have proven very effective in treating psoriasis patients. When used in combination with topical and systemic treatment, light therapy can be highly successful. Light therapy is especially useful when patients start to develop a resistance to topical steroids. The key to successful treatment of psoriasis with light therapy is consistent, long term, disciplined treatment sessions.

There are two main forms of light therapy administered by doctors.

1. UV-B or Ultraviolet B: Ultraviolet light B is present in natural sunlight and can help psoriasis patients by decreasing the rapid cell growth. "UVB penetrates the skin and slows the abnormally rapid growth of skin cells associated with psoriasis. UVB treatment involves exposing the skin to an artificial UVB light source for a set length of time on a regular schedule, either under a doctor's direction in a medical setting or with a home unit purchased with a doctor's prescription."(1) Treatment times and frequency vary according to patient.

There are two types of UVB light, broad band and narrow band. Broad is most widely used in the United States, however, narrow band is starting to gain popularity as a treatment among doctors as it seems to be more effective.

2. PUVA: PUVA is a different type of light therapy then UV-B used for the treatment of psoriasis. PUVA is an acronym that stands for Psoralen UltraViolet-A light, or Psoralen UVA. Similar to UV-B, UVA light by itself is not effective for the treatment of psoriasis. Under PUVA light therapy, a medication called psoralen is orally or topically applied to make the skin more receptive to UV-A light. Ultraviolet-A has a long wave-length that penetrates deeper into the skin.(2)

According to NIAMS, PUVA is used when more than 10 percent of the body is covered or affected by psoriasis plaques, or when the affected areas interfere with the patient's profession such as the hands of a teacher or salesperson.

"Compared with broadband UVB treatment, PUVA treatment taken two to three times a week clears psoriasis more consistently and in fewer treatments. However, it is associated with more shortterm side effects, including nausea, headache, fatigue, burning, and itching. Care must be taken to avoid sunlight after ingesting psoralen to avoid severe sunburns, and the eyes must be protected for one to two days with UVA-absorbing glasses. Long-term treatment is associated with an increased risk of squamous-cell and, possibly, melanoma skin cancers. Simultaneous use of drugs that suppress the immune system, such as cyclosporine, have little beneficial effect and increase the risk of cancer." (2)

Light therapy is usually more effective when used in combination with topical or systemic treatment options, then as a stand alone treatment. As mentioned above, it is worth restating that for light therapy to be effective, long-term, consistent treatment sessions are needed. Home units can be purchased with a doctor's prescription and are usually worth the investment for the 35 percent of patients who have moderate to severe psoriasis. Talk to your doctor for more information.

Systemic Therapy
In moderate to sever cases of psoriasis, or when psoriasis won't go into remission with topical and light therapy, doctor's may prescribe internal medicines that are taken orally or by injection. These medications carry side-effects your doctor or pharmacist or prescription fact sheet should inform you about. The most common systemic medications include:

Methotrexate: Slows cell production by suppressing the immune system.

Cyclosporine: Like methotrexate, cyclosporine works by suppressing the immune system and reducing the skin cell turnover rate. Cyclosporine should not be used with Light Therapy.

Retinoids (Soriatane): Soriatane is a prescription medication called an oral retinoid, which is a synthetic form of vitamin A and is approved by the FDA for the treatment of psoriasis. According to the National Psoriasis Foundation, it is not exactly clear how oral retinoids benefit those with psoriasis, but is believed to assist cells in how they regulate their behavior. "Retinoids help control how cells multiply, including how fast skin cells will grow and shed from the skin's surface." (1)

Biologic Response Modifiers (Biologics): Unlike other medicines which are made from chemical compounds, biologics are made from human or animal proteins. They have been in use for 100s of years but have only recently been steered towards and applied to patients with psoriasis. A new class of medicines from biologics have emerged recently and are proving effective in treating psoriasis. The most frequently prescribed of these biologic medicines include:

Alefacept (brand name Amevive): Amevive was approved by the FDA in January of 2003 for the treatment of psoriasis. It is an immune suppressing drug that reduces the T cells that can cause psoriasis plaques. Amevive is prescribed to patients with moderate to severe psoriasis and can be used in conjunction with phototherapy.
Etanercept (brand name Enbrel): Enbrel was approved by the FDA in January 2002 for the treatment of both psoriatic arthritis and psoriasis. Enbrel works by controlling the cytokines which lead to inflammation.
Adalimumab (brand name Humira): Humira was approved by the FDA in October 2005 for the treatment of rheumatoid arthritis and psoriatic arthritis. It is currently being studied as a treatment for psoriasis. According to the NPF, "...some doctors are already prescribing it "off-label" for this disease—a common and accepted medical practice." (1)
Efalizumab (brand name Raptiva): Raptiva was approved by the FDA in October 2003 for treatment of moderate to severe plaque psoriasis. Raptiva works on the T cells which lead to plaque build ups and inflammation.

Article by Jason Morrow,
OmniMedicalSearch.com

SOURCES:
(1) National Psoriasis Foundation
(2) National Institute of Arthritis and Musculoskeletal and Skin Diseases, Questions and Answers about Psoriasis, May 2003
(3) American Academy of Dermatology, Psoriasis Pamphlet, August 2005
(4) American Academy of Family Physicians, Psoriasis, 2006
(5) EmedicineHealth.com, Psosriasis, by Hon Pak, MD, January 2006
(6) University of British Columbia, DermWeb, Psoriasis: What is it and How is it Treated?
(7) American Journal of Human Genetics, Sequence and haplotype analysis supports HLA-C as the psoriasis susceptibility 1 gene, 2006