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What is psoriasis?
Psoriasis is an incurable chronic autoimmune disorder of the skin that causes patches of thick, flaky, scaly skin, mostly around the scalp, knees, and elbows, though any skin surface may be involved. Some people experience only small patches while others have red, inflamed skin and think scaly patches all over the body. The exact cause of psoriasis is not clear, but it isn’t contagious.
What is the treatment for psoriasis?
Psoriasis is not currently curable. However, it can go into remission, producing an entirely normal skin surface. Ongoing research is actively making progress on finding better treatments and a possible cure in the future.
There are many effective psoriasis treatment choices. The best treatment is individually determined by the treating doctor and depends, in part, on the type of disease, the severity, and amount of skin involved and the type of insurance coverage.
For mild disease that involves only small areas of the body (less than 10% of the total skin surface), topical treatments (skin-applied), such as creams, lotions, and sprays, may be very effective and safe to use. Occasionally, a small local injection of steroids directly into a tough or resistant isolated psoriatic plaque may be helpful.
For moderate to severe psoriasis that involves much larger areas of the body (>10% or more of the total skin surface), topical products may not be effective or practical to apply. This may require ultraviolet light treatments or systemic (total body treatments such as pills or injections) medicines. Internal medications usually have greater risks. Because topical therapy has no effect on psoriatic arthritis, systemic medications are generally required to stop the progression to permanent joint destruction.
It is important to keep in mind that as with any medical condition, all medicines carry possible side effects. No medication is 100% effective for everyone, and no medication is 100% safe. The decision to use any medication requires thorough consideration and discussion with your health care provider. The risks and potential benefit of medications have to be considered for each type of psoriasis and the individual. Of two patients with precisely the same amount of disease, one may tolerate it with very little treatment, while the other may become incapacitated and require treatment internally.
A proposal to minimize the toxicity of some of these medicines has been commonly called "rotational" therapy. The idea is to change the anti-psoriasis drugs every six to 24 months in order to minimize the toxicity of one medication. Depending on the medications selected, this proposal can be an option. An exception to this proposal is the use of the newer biologic medications as described below. An individual who has been using strong topical steroids over large areas of their body for prolonged periods may benefit from stopping the steroids for a while and rotating onto a different therapy.
Coal tar shampoos are very useful in controlling psoriasis of the scalp. Using the shampoo daily can be very beneficial adjunctive therapy. There are a variety of over-the-counter shampoos available without a prescription. There is no evidence that one shampoo is superior to another. Generally, the selection of a tar shampoo is simply a matter of personal preference.
Oral medications for psoriasis
Oral medications include methotrexate (Trexall), acitretin (Soriatane), cyclosporine (Neoral), apremilast (Otezla), and others. Oral prednisone (corticosteroid) is generally not used in psoriasis and may cause a disease flare-up if administered.
- Acitretin (Soriatane) is an oral drug used for certain types of psoriasis. It is not effective in all types of the disease. It may be used in males and females who are not pregnant and not planning to become pregnant for at least three years. The major side effects include dryness of skin and eyes and temporarily elevated levels of triglycerides and cholesterol (fatty substance) in the blood. Blood tests are generally required before starting this therapy and are needed periodically to monitor triglyceride levels. Patients should not become pregnant while on this drug and usually avoid becoming pregnant for at least three years after stopping this medication.
- Cyclosporine is a potent immunosuppressive drug used for other medical uses, including organ transplantation. It may be used for severe, difficult-to-treat cases of widespread psoriasis. Improvement and results may be very rapid in onset. It may be hard to get someone off of cyclosporine without flaring their psoriasis. Because of the potential cumulative toxicity, cyclosporine should not be used for more than one to two years for most psoriasis patients. Major possible side effects include kidney and blood-pressure problems.
- Methotrexate is a common drug used for rheumatoid arthritis, and it has been used effectively for many years in psoriasis. It is usually given in small weekly doses (5 mg-25 mg), either orally or by injection. Blood tests are required before and during therapy. The drug may cause liver and lung damage. Close physician monitoring and monthly to quarterly visits and labs are generally required.
- FDA has approved a new oral drug, apremilast (Otezla), to treat psoriasis and psoriatic arthritis, with an entirely novel mode of action (inhibition of an enzyme, phosphodiesterase 4) and does not require intensive laboratory monitoring.
What are topical remedies for psoriasis?
Topical (skin applied) treatments include topical corticosteroids, vitamin D analogue creams like calcipotriene (Calcitrene, Dovonex, Sorilux), topical retinoids (tazarotene [Tazorac]), moisturizers, topical immunomodulators (tacrolimus and pimecrolimus), coal tar, anthralin, and others.
- Topical corticosteroids (steroids, such as hydrocortisone) are very useful and often the first-line treatment for limited or small areas of psoriasis. These come in many preparations, including sprays, liquid, creams, gels, ointments, and foams. Steroids come in many different strengths, including stronger ones that are used for elbows, knees, and tougher skin areas and milder ones for areas like the face, underarms, and groin. These are usually applied once or twice a day to affected skin areas. Strong steroid preparations should be limited in use. Overuse or prolonged use may cause problems, including potential permanent skin thinning and damage called atrophy.
- Calcipotriene cream is useful in psoriasis because of its effect on calcium metabolism. The advantage of calcitriol is that it is not known to thin the skin like topical steroids. There is a newer combination preparation of calcipotriene and a topical steroid called Taclonex. Not all patients may respond to calcipotriene. Prolonged use of these types of medications on more than 20% of the skin surface can produce an abnormal rise in body calcium levels.
- Moisturizers, especially with therapeutic concentrations of salicylic acid, lactic acid, urea, and glycolic acid may be helpful in psoriasis. These moisturizers are available as prescription and nonprescription forms. These help reduce the scales that impede the movement of topical medications into the deeper layers of the skin. Some available preparations include salicylic acid (Salex) and lactic acid (AmLactin, Lac-Hydrin). These may be used one to three times a day on the body. Other bland moisturizers, including Vaseline and Crisco vegetable shortening, may also be helpful in at least reducing the dry appearance of psoriasis.
- Immunomodulators (tacrolimus and pimecrolimus) have also been used with some limited success in mild psoriasis. These have the advantage of not causing skin thinning. They may have other potential side effects, including skin infections and possible malignancies (cancers). The exact association of these immunomodulator creams and cancer is controversial.
- Bath salts or bathing in high-salt-concentration waters like the Dead Sea in the Middle East along with careful exposure to sunlight can be beneficial to psoriasis patients.
- Coal tar is available in multiple preparations, including shampoos, bath solutions, and creams. Coal tar may help reduce the appearance and decrease the flakes in psoriasis. The odor, staining, and overall messiness with coal tar may make it less desirable than other therapies. A major advantage with tar is lack of skin thinning.
- Anthralin is available for topical use as a cream, ointment, or paste. The stinging, possible irritation, and skin discoloration may make this less acceptable to use. Anthralin may be applied for 10-30 minutes to psoriatic skin.
What kind of doctor treats psoriasis?
Dermatologists are doctors who specialize in the diagnosis and treatment of psoriasis, and rheumatologists specialize in the treatment of joint disorders and psoriatic arthritis. Many kinds of doctors may treat psoriasis, including dermatologists, family physicians, internal medicine physicians, rheumatologists, and other medical doctors.
The American Academy of Dermatology and the National Psoriasis Foundation are excellent sources to help find doctors who specialize in this disease. Not all dermatologists and rheumatologists treat psoriasis. The National Psoriasis Foundation has one of the most up-to-date databases of current psoriasis specialists.
It is now apparent that patients with psoriasis are prone to a variety of other associated disease conditions. Cardiovascular disease, diabetes, hypertension, inflammatory bowel disease, hyperlipidemia, liver problems, and arthritis are more common in patients with psoriasis. It is very important for all patients with psoriasis to be carefully monitored by their primary care providers for these associated illnesses.
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Conrad, Curdin, Michel Gilliet. "Psoriasis: From Pathogenesis to Targeted Therapies." Clinical Reviews in Allergy & Immunology Jan. 18, 2015.
Dowlatshahi, E.A., E.A.M van der Voort, L.R. Arends, and T. Nijsten. "Markers of Systemic Inflammation in Psoriasis: A Systematic Review and Meta-Analysis." British Journal of Dermatology 169.2 Aug. 2013: 266–282.
Greb, Jacqueline E., et al. "Psoriasis." Nature Reviews Disease Primers 2 (2016): 1-17.
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