Psoriasis Treatments
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- Category: Light For Hope
- Created on Friday, 02 December 2011 04:28
- Last Updated on Monday, 05 December 2011 23:27
- Published on Friday, 02 December 2011 04:28
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Treatment of Psoriasis basically depends on disease severity, patient age, the existence of articular affections, presence of comorbidities, previous therapies and any adverse events in your medical history.
Treating moderate to severe psoriasis usually involves a combination of treatment strategies. Besides topical treatments, your doctor may prescribe Phototherapy (also known as light therapy) and/or systemic medications, including Biologic drugs.
TOPICALS
Topical medications applied to the skin are usually the first line of defense in treating psoriasis. Topicals slow down or normalize excessive cell reproduction and reduce the inflammation associated with psoriasis.
Thick, over-the-counter ointments and lotions with emollients may help soften and soothe dry skin.
There are many effective topical treatments for psoriasis. While many can be purchased over the counter (OTC), others are available by prescription only.
Corticosteroids, or just "steroids" are the most frequently used treatment for psoriasis. They are referred to as anti-inflammatory agents, because they reduce the swelling and redness of the lesions. Anthralin, synthetic Vitamin D3, and Vitamin A are also used in prescription topical treatments to control psoriasis lesions.
OTC topicals come in many different forms. Two active ingredients, salicylic acid and coal tar, are approved by the FDA for the treatment of Psoriasis. There are other products that contain substances such as aloe vera, jojoba, zinc pyrithione and capsaicin, which are used to moisturize, soothe, remove scale or relieve itching.
Topical anti-inflammatory agents have been a mainstay of primary and maintenance therapy for plaque psoriasis. Clinical recommendations from the American Academy of Dermatology cited topical corticosteroids as the first option for limited psoriasis. Other options included vitamin D analogues, retinoids, tacrolimus, and Phototherapy (J Am Acad Dermatol 2011; epub).
SYSTEMICS
Systemic medications are prescription drugs that work throughout the body. They are usually used for individuals with moderate to severe psoriasis and psoriatic arthritis. Systemic medications are also used in those who are not responsive or are unable to take topical medications or UV light therapy.
Systemic psoriasis drugs are taken by mouth in liquid or pill form or given by injection and fall into two categories: "traditional systemics" and "biologics." Traditional systemics have been used for more than 10 years. Biologics are a relatively new class of treatments for psoriasis and psoriatic arthritis.
Traditional Systemics Are:
Acitretin (Soriatane)
Soriatane is an oral retinoid, which is a synthetic form of vitamin A. Acitretin is the only oral retinoid approved by the FDA specifically for treating psoriasis. The exact way Soriatane works to control psoriasis is unknown. In general, retinoids help control the multiplication of cells including the speed at which skin cells grow and shed.
Cyclosporine
Cyclosporine is an immunosuppressive drug that was first used to help prevent rejection in organ transplant patients. In 1997, the Food and Drug Administration (FDA) approved Neoral for adults with severe psoriasis and otherwise normal immune systems. Cyclosporine suppresses the immune system and slows down the growth of certain immune cells.
Methotrexate
Approved by the FDA in the 1970s for treatment of severe psoriasis, methotrexate was initially used to treat cancer. The drug is also highly effective in reducing the painful symptoms of psoriatic arthritis. In a person with psoriasis, methotrexate binds to and inhibits an enzyme involved in the rapid growth of skin cells and slows down their growth rate.
Do not take methotrexate if:
•You are an alcoholic or have alcoholic liver disease, cirrhosis or other chronic liver diseases;
•You have an immunodeficiency syndrome or an active infectious disease;
•You are trying to conceive (applies to both men and women), pregnant or nursing;
•You have an active peptic ulcer;
•You have significant liver or kidney abnormalities;
•You have underdeveloped bone marrow, a low white blood cell count, low platelets or significant anemia.
The less common side effects of long-term methotrexate treatment include liver damage and reversible living scarring developing reversible liver scarring. The risk of liver damage increases if a person drinks alcohol, has abnormal kidney function, is obese, has diabetes or has had prior liver disease. Years after the drug, in rare occasions, certain types of cancer, such as lymphoma, and bone marrow toxicity have occurred. Methotrexate can cause a reduced white blood cell count increasing infection risk.
Individuals taking methotrexate must have regular blood tests to ensure that the drug is safely processed by the body including the liver, white blood cells and bone marrow. Additionally, the liver must be biopsied at regular intervals.
Pregnancy should be avoided if either partner is taking methotrexate. Men should be off methotrexate at least three months before trying to conceive. Women should wait at least four months after stopping methotrexate to become pregnant.
Off-label systemics.
There are additional systemic medications that are not approved by the FDA for the treatment of psoriasis or psoriatic arthritis. However, some doctors prescribe them off-label. This is an accepted medical practice commonly used by the most experienced dermatologist.
Hydrea (hydroxyurea) is an oral cancer medication found to be effective for psoriasis in the late 1960s. Hydrea can produce significant improvement in stable plaque psoriasis, but it also has potentially dangerous side effect, including bone marrow toxicity. Long-term use has been associated with skin cancer.
Isotretinoin is an oral retinoid approved as a treatment for severe cystic acne. The most common side effects of isotretinoin are eye and lip dryness, and nosebleeds. Bone spurs and hair loss occur to a lesser degree.
Isotretinoin has the potential for severe birth defects if a woman becomes pregnant while the drug is still in her system. A woman on Isotretinoin should use reliable birth control one month before treatment, during treatment and for at least one month afterward.
Mycophenolate mofetil is used for the prevention of organ transplant rejection, as well as in the treatment of several inflammatory or autoimmune skin diseases. It has been used in combination with cyclosporine. Because it is an immunosuppressive agent, people with compromised immune systems should not take it.
Sulfasalazine is a combination anti-inflammatory and antibiotic commonly used for treating psoriatic arthritis. Many people cannot tolerate sulfasalazine because of allergy to sulfa, or because of side effect, including nausea, vomiting and loss of appetite.
6-thioguanine is an oral medication approved for treating certain types of leukemia. 6-Thioguanine has been reported to be effective for psoriasis, including treatment of pustular psoriasis. 6-Thioguanine must be used under close supervision due to the potential side effects associated with suppression of the bone marrow.
BIOLOGICS
Biologic drugs, or "biologics," are a relatively new class of treatment for psoriasis and psoriatic arthritis treatments. They are given by injection or intravenous (IV) infusion.
A biologic is a protein-based drug derived from living cells cultured in a laboratory. While biologics have been used to treat disease for more than 100 years, the advent of modern day molecular biologic techniques has accelerated their use in modern day medicine tremendously in the last decade.
Different from the traditional systemic drugs that impact the entire immune system, biologics target specific parts of the immune system. The biologics used to treat psoriatic diseases act by blocking the action of a specific type of immune cell called a T cell, or by blocking proteins in the immune system, such as tumor necrosis factor-alpha (TNF-alpha) or interleukins 12 and 23. These cells and proteins all play a major role in developing psoriasis and psoriatic arthritis.
T-cell blockers.
Amevive (alefacept) works by blocking the activation of a type of white blood cell called a T cell, which results in a reduction in skin inflammation. T cells normally help the body rid itself of foreign invaders such as viruses, fungi and bacteria. However, in psoriasis the T cell mistakenly attacks the skin; this sets off a chain or "cascade" of events that causes psoriasis lesions to form and become inflamed.
Raptiva (efalizumab), a biologic that blocks the activation of T-cells, was approved in 2003 by the FDA. It was voluntarily taken off the market in 2009 due to safety concerns. For more information about this matter, visit the Food and Drug Administration's website.
Tumor necrosis factor-alpha (TNF-alpha) blockers
Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab) and Simponi (golimumab) are drugs that block TNF-alpha. TNF-alpha is an immune system mediator called a cytokine that is a key mediator of inflammation. In psoriasis and psoriatic arthritis, there is excess production of TNF-alpha in the skin or joints that leads to the rapid growth of skin cells and/or damage to joint tissue. Blocking the TNF-alpha helps to stop the inflammatory cycle of psoriatic diseases.
Interleukin 12/23
Stelara (ustekinumab) works by selectively targeting the cytokines interleukin-12 (IL12) and interleukin 23 (IL23). Interleukins-12/23 are also cytokines which are thought to promote the inflammation associated with psoriasis.
How are they used?
The biologics are taken by injection or by IV infusion. Amevive is administered by intramuscular injection in a medical office. Enbrel, Humira and Simponi are injected in the legs, abdomen or arms, typically by the individual with psoriasis or a family member. Stelara is administered as a subcutaneous injection by a health care provider. Remicade is given through IV infusion in a doctor's office or infusion center.
Biologics are prescribed for individuals with moderate to severe cases of plaque psoriasis and psoriatic arthritis. They are a viable option for those who have not responded to or have experienced harmful side effects from other treatments. The TNF blockers have been shown to reduce the progression of joint damage in psoriatic arthritis.
Do not take Biologics if:
•Your immune system is significantly compromised;
•You have an active infection.
Screening for tuberculosis (TB) or other infectious diseases is required before starting treatment with Enbrel, Humira, Remicade, Simponi and Stelara.
What are the risks?
Anyone considering taking a biologic drug should talk with his or her doctor about the short- and long-term side effects and risks. It is important to weigh the risks against the benefits of using the drugs.
Biologics can increase the risk of infection. Individuals who develop any sign of an infection such as a fever, cough or flu-like symptoms or have any cuts or open sores should contact their doctor right away.
The impact of biologics on a developing fetuses or nursing infants is not known. Biologics should only be prescribed to pregnant or nursing women if there is a clear medical need.
Common side effects for biologics include:
•Respiratory infections
•Flu-like symptoms
•Injection site reactions
These side effects are generally mild and in most cases do not cause individuals to stop taking the medication.
Rare side effects for biologics include:
•Serious nervous system disorders, such as multiple sclerosis, seizures, or inflammation of the nerves of the eyes have;
•Blood disorders;
•Certain types of cancer.
Call your doctor if you are experiencing any side effects with biologic drugs. For specific side effect information, download the individual product fact sheet.
Using biologics with other psoriasis treatments
All of the biologics currently on the market can be used with other treatments such as phototherapy or topicals. There is data that suggests that phototherapy in combination with Amevive may improve the outcome. Using phototherapy along with Remicade may increase your risk of skin cancer.
Enbrel, Humira, and Remicade are shown to be safe and effective when taken with methotrexate. Talk to your doctor about whether using any other treatments with a biologic is right for you
