Psoriasis Medication

Many drugs that affect the rate of skin cell production are used in psoriasis therapy alone or in combination with light therapy, stress reduction, and climatotherapy. Adjuncts to treatment include sunshine, moisturizers, and salicylic acid as a scale-removing agent. Generally, these therapies are used for patients with less than 20% of body surface area involved, unless the lesions are physically, socially, or economically disabling.

Treatments for more advanced psoriasis include narrow-band ultraviolet B (UVB) light, psoralen with ultraviolet A (UVA) light retinoids (eg, isotretinoin [Accutane, Claravis], acitretin [Soriatane]), methotrexate (particularly for arthritis), cyclosporine (Neoral, Sandimmune), infliximab (Remicade), etanercept (Enbrel), adalimumab (Humira), and alefacept (Amevive).

The AAD guidelines recommend treatment with methotrexate, cyclosporine, and acitretin, with consideration of the contraindications and drug interactions noted in the discussion of each medication below.^[24]

Class Summary

Topical corticosteroids are used to reduce plaque formation. These agents have anti-inflammatory effects and may cause profound and varied metabolic activities. In addition, they modify the body’s immune response to diverse stimuli.

Several examples are provided, but no topical corticosteroids are superior in efficacy or adverse effects to others in the same class. Some formulations such as foams and solutions are easier to use in the scalp than either creams or ointments. A patient who has been doing well on a topical steroid who begins to have worsening, especially with itching, should be evaluated for either a concomitant fungal infection or the development of allergic contact dermatitis to a steroid or vehicle component.

Triamcinolone acetonide (Aristocort, Kenalog) 0.025-0.1% cream

Triamcinolone treats inflammatory dermatosis responsive to steroids. It decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. It has mild potency and is the first drug of choice for most patients.

Betamethasone (Diprolene, Diprosone) 0.025-0.1% cream

Betamethasone treats inflammatory dermatosis responsive to steroids. It decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. It is a potent topical steroid and is the drug of choice if psoriasis is resistant to milder forms.

Class Summary

Ophthalmic corticosteroids treat conjunctival, corneal, and anterior chamber inflammation. These agents help control infiltration and delay vascularization.

Prednisolone acetate 1% ophthalmic (Pred Forte)

Prednisolone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely.

Dexamethasone ophthalmic

Dexamethasone is used for various allergic and inflammatory diseases. It decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Class Summary

Coal tar is an inexpensive treatment that is available over the counter in shampoos, lotions, creams, or foam for use in widespread areas of involvement. It is particularly useful in hair-bearing areas. Some recent research has shown the 1% concentration may be superior in control of lesions to more concentrated preparations. Tar preparations may be especially useful when combined with topical corticosteroids. This may be accomplished by applying the products sequentially or, when available, obtaining them from a compounding pharmacy.

Coal tar 0.5-33% (DHS Tar, Doctar, Theraplex T)

Coal tar is antipruritic and antibacterial and inhibits deregulated epidermal proliferation and dermal infiltration. It does not injure the normal skin when applied widely, and it enhances the usefulness of phototherapy. It generally is used as a second-line drug therapy due to messy application, except for shampoos, which may be used and rinsed at once.

Class Summary

Keratolytic agents are used to remove scale, to smooth the skin, and to treat hyperkeratosis.

Removing the thick scale allows topical corticosteroids and other topical medications to better reach the target tissues and achieve better results. This is especially important on the scalp. Many over-the-counter preparations can be used for this, most of which contain salicylic acid. Lactic acid, ammonium lactate, and urea are other ingredients that may be applied before or at the same time as other topical medications. Urea preparations stronger than 30% require a prescription, a variety of creams, lotions, and foams are available for this. Many “foot creams” contain combinations of keratolytics and may be applied to any area of the body needing scale removal.

Anthralin is also considered to be in the antipsoriatic therapeutic class.

Anthralin (Drithocreme, Anthra-Derm)

Anthralin reduces the rate of cell proliferation. Its chemically reducing properties may also upset the oxidative metabolic processes, further reducing epidermal mitosis. It is not the first or second drug of choice due to irritation problems of normal skin surrounding lesions and staining of the skin.

Class Summary

Vitamin D analogs are used in patients with lesions resistant to topical therapy or with lesions on the face or exposed areas where thinning of the skin would pose cosmetic problems. These come as ointments, solutions, and foams. The latter 2 are especially useful for scalp treatments.

Calcitriol (Vectical) Ointment

Calcitriol is a topical vitamin D analog similar to calcipotriene but seems to be less irritating in sensitive areas of skin.

Calcipotriene (Dovonex, Sorilux)

Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. It is used in the treatment of moderate plaque psoriasis. This treatment does not cause long-term skin thinning or systemic effects. Sorilux is a newer foam version of this medication.

Calcipotriene and betamethasone topical ointment (Taclonex)

Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. It inhibits epidermal proliferation, promotes keratinocyte differentiation, and has immunosuppressive effects on lymphoid cells. Betamethasone is a corticosteroid that decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. The combination is available as a topical ointment and as a scalp solution containing calcipotriene 0.005% and betamethasone dipropionate 0.064%.

The product is quite expensive and the same results may be obtained by using a generic corticosteroid sequentially in combination with one of the other vitamin D analog products.

Class Summary

Aqueous gel formulations are odorless and colorless, and no long-term skin damage has been noted with topical retinoids. There is also no threat of worsening if the therapy is withdrawn, as with steroids. These drugs should not be used in women if pregnancy is a possibility.

Tazarotene (Tazorac) aqueous gel and cream 0.05% and 0.1%

Tazarotene is a retinoid prodrug that is converted to its active form in the body and modulates differentiation and proliferation of epithelial tissue and perhaps has anti-inflammatory and immunomodulatory activities. It may be the drug of choice for those with facial lesions who are not at risk of pregnancy.

Tazarotene, although topical, is a category X medication. Topical tretinoin is of less use in psoriatic patients. A strategy that may be tried in patients who experience unacceptable irritation is to use short contact times. There are several protocols, but the least irritating is to apply the medication for 15-20 min and then wash off. The total time on may be increased by 15-20 minutes every few weeks until clinical efficacy or adverse cutaneous effects are seen. This short-contact method may be especially useful when one is using it in skin folds but is less effective for the plaque with very thick scale.

Class Summary

Antimetabolites inhibit cell growth and proliferation.

Methotrexate (Trexall)

Methotrexate inhibits dihydrofolic acid reductase. Dihydrofolates must be reduced to tetrahydrofolates by this enzyme before they can be utilized as carriers of one-carbon groups in the synthesis of nucleotides and thymidylate. Subsequently, methotrexate interferes with DNA synthesis, repair, and cellular replication. Actively proliferating tissues are in general more sensitive to this effect of methotrexate.

Class Summary

Immunomodulators regulate key factors responsible for inflammatory response.

Tacrolimus topical 0.1% (Protopic)

Topical tacrolimus has been used in the past for management of refractory atopic dermatitis. However, multiple studies have shown effectiveness with psoriasis affecting intertriginous regions as well as the face. Generally, it seems to be effective in thin-skinned areas. However, it has become somewhat of a second-line agent given other studies showing topical steroids may be more effective and potential serious disease association.

Cyclosporine (Sandimmune, Neoral)

Cyclosporine is an 11-amino acid cyclic peptide and natural product of fungi. It acts on T-cell replication and activity.

Cyclosporine is a specific modulator of T-cell function and an agent that depresses cell-mediated immune responses by inhibiting helper T-cell function. Preferential and reversible inhibition of T lymphocytes in the G0 or G1 phase of cell cycle is suggested. The drug binds to cyclophilin, an intracellular protein, which, in turn, prevents formation of interleukin (IL)-2 and the subsequent recruitment of activated T cells.

Cyclosporine has about 30% bioavailability, but there is marked interindividual variability. It specifically inhibits T-lymphocyte function with minimal activity against B cells. Maximum suppression of T-lymphocyte proliferation requires that the drug be present during first 24 h of antigenic exposure.

Cyclosporine suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions (eg, delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft versus host disease) for a variety of organs.

Cyclosporine is used in extensive disease refractory to other treatments, especially when used at 5 mg/kg/d. Remission is usually rapid with this therapy; however, skin lesions tend to recur within days to weeks after treatment is stopped (although patients do not usually have the severe rebound that patients withdrawing from therapy may have). Maintenance therapy (3 mg/kg/d) usually is required with lower doses of this drug.

Alefacept (Amevive)

Alefacept is a recombinant dimeric fusion protein that binds to CD2 on memory-effector T lymphocytes, thereby inhibiting the activation of these cells and reducing the number of these cells. It is indicated for moderate to severe psoriasis. This drug usually is administered intramuscularly.

Ustekinumab (Stelara)

Ustekinumab is a human monoclonal antibody directed against IL-12 and IL-23, thereby interfering with T-cell differentiation and activation and subsequent cytokine cascades. It is indicated for moderate-to-severe plaque psoriasis.

Class Summary

These agents neutralize the effects of tumor necrosis factor-α (TNF-α).

For adalimumab, weight-based dosing regimens exist for pediatric-aged patients.

For etanercept, some patients will require twice-weekly dosing of the induction period indefinitely in order to maintain satisfactory control.

Infliximab (Remicade)

Infliximab is a chimeric antibody that binds both the soluble and transmembrane TNF-α molecules, thereby neutralizing the effects of TNF-α. It is indicated for chronic severe (ie, extensive and/or disabling) plaque psoriasis in adults who are candidates for systemic therapy and when other systemic therapies are medically less appropriate. It is also indicated to reduce signs and symptoms, and to improve physical function of patients with psoriatic arthritis. Screen patients for tuberculosis (TB) and hepatitis B, as reactivation of both illnesses is associated with TNF-α inhibitors.

This drug is delivered by infusion only.

Etanercept (Enbrel)

Etanercept is a recombinant human TNF-α receptor protein fused with the Fc portion of IgG1 that binds to soluble and membrane-bound TNF-α, thereby neutralizing the effects of TNF-α. It is indicated for moderate-to-severe psoriasis and moderate-to-severe psoriatic arthritis. Screen patients for TB and hepatitis B, as reactivation of both illnesses is associated with TNF-α inhibitors.

Adalimumab (Humira)

Adalimumab is a fully human anti–TNF-α monoclonal antibody. It binds specifically to soluble and membrane-bound TNF-α, thereby neutralizing the effects of TNF-α. It is used to treat moderate-to-severe psoriasis and moderate-to-severe psoriatic arthritis. Screen patients for TB and hepatitis B, as reactivation of both illnesses is associated with TNF-α inhibitors.

Class Summary

Ustekinumab (Stelara) is a human monoclonal antibody directed against interleukin-12 and interleukin-23. It is indicated for moderate to severe psoriasis. Patients should be screened for tuberculosis and hepatitis B virus, as reactivation of both illnesses is associated with TNF-α inhibitors. It is approved in two dosages, administered subcutaneously, with the higher dose given to those weighing 100 kg (220 pounds) or more. It has been suggested that 91 kg (200 pounds) might be a better cutoff for the higher dose for optimal control.^[32]

Ustekinumab

Human monoclonal antibody directed against IL-12 and IL-23, thereby interfering with T-cell differentiation and activation and subsequent cytokine cascades. Indicated for moderate-to-severe plaque psoriasis.

Class Summary

Artificial tears are used to treat dry eye irritation. Many types of artificial tears are available over the counter. In mild cases, preserved tears can be used. In severe cases, only nonpreserved tears should be used. Preserved tears include GenTeal, Refresh Tears, and Tears Naturale II. Nonpreserved tears include Refresh, Refresh Plus, OcuCoat, Bion, and Hypo Tears PF.

Artificial tears

Artificial tears contain the equivalent of 0.9% NaCl and are used to maintain ocular tonicity. They act to stabilize and thicken precorneal tear film and prolong tear film breakup time, which occurs with dry eye states.

Class Summary

Intramuscular corticosteroids are not recommended for the management of psoriasis because of the risk of flare upon withdrawal. On the other hand, isolated plaques may be injected intralesionally, as may the nail matrix in cases of severe psoriatic nails.

Triamcinolone

For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Many other topical steroids also are available.

Up to 0.4 mL may be injected, after ring block, into the nail bed and matrix to improve psoriatic dystrophy. Results may be long lasting but more than one treatment may be required.