Psoriasis Treatment & Management

Management of psoriasis may involve drugs, light therapy, stress reduction, climatotherapy, and various adjuncts such as sunshine, moisturizers, and salicylic acid.

The American Academy of Dermatology (AAD) is developing a series of recommendations under the umbrella title, Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis. The most recent addition was Section 6 (published online in November 2010; in print 2011.) All 6 sections are available online at the AAD website.^{[21, 22, 23, 24, 25]} Section 6 of the AAD guideline recommends that psoriasis treatment be personalized for each patient’s clinical situation and discusses examples of this approach to treatment.^[25]

Patients with guttate, erythrodermic, or pustular psoriasis may present to the emergency department. In each of these cases, restoration of the barrier function of the skin is of prime concern. This can be performed with cleaning and bandaging.

Plaque and scalp lesions are frequently encountered in patients seeking care for other problems, and initial treatment of the lesions should be offered.

The simplest treatment of psoriasis is daily sun exposure, sea bathing, topical moisturizers, and relaxation. Moisturizers, such as petrolatum jelly, are helpful. Daily application of moisturizing cream to the affected area is inexpensive and successful adjunct to psoriasis treatment. Application immediately after a bath or shower helps to minimize itching and tenderness. Section 3 (2009) of the AAD guideline discusses topical agents and recommends their use adjunctively but not as monotherapy if the disease is extensive or recalcitrant.^[22]

Nonprescription tar preparations are available and have therapeutic success, especially when used in conjunction with topical corticosteroids; the newer foams are less messy preparations than some of the older ones. Anthralin, topical corticosteroids, salicylic acid, phenolic compounds, and calcipotriene (a vitamin D analog) also may be effective. Systemic corticosteroids are generally ineffective, and they can significantly exacerbate the disease upon withdrawal. Combination therapy with a vitamin D analog (calcipotriol and calcipotriene) or a retinoid such as tazarotene and a topical corticosteroid is more effective than therapy with either agent alone.^[26] Oatmeal baths may be helpful.

Solar or ultraviolet radiation may be helpful. Various ultraviolet light treatments are used—most commonly, psoralen-ultraviolet A (PUVA) therapy. Among phototherapy options, Section 5 (2010) of the AAD guideline gives the highest recommendation to oral PUVA or a combination of PUVA and topical agents.^[24] Psoralen is a photosensitizer that is ingested prior to light exposure. PUVA treatment results in conjunctival hyperemia and dry eye, particularly if sun protection is not used. With proper eye protection, there does not appear to be a risk of cataract. Psoralens for either topical (bath) or systemic use may occasionally be difficult to obtain because of stocking shortages.

According to the AAD guidelines, PUVA can result in long remissions, but long-term use of PUVA in Caucasians may increase the risk of squamous cell carcinoma and possibly malignant melanoma.^{[21, 24]}

Narrow-band ultraviolet B (UVB) therapy has always been accepted as a good treatment modality of psoriasis and the AAD guidelines recommend it over broad-band (UVA), although both are less effective than PUVA.^{[21, 24]} As with PUVA, the guidelines also recommend treatment with combinations of UVB and topic or systemic agents.^[24] However, a study by Keaney and Kirsner gives objective reasoning for the benefit of narrow-band UV therapy by showing decreases in T cells, dendritic cells, and interleukins within responsive psoriatic plaques compared with plaques that did not respond to therapy.^[5] Gutate psoriasis may prove especially responsive to phototherapy. Therapies such as UVB and PUVA have low efficacy for the treatment of nail psoriasis because of the blockage of the UV radiation by the intervening nail plate.^[27]

Patients with psoriasis should avoid injury to skin, including sunburn and other physical trauma, as these areas may develop psoriasis. The appearance of psoriatic lesions in previously uninvolved areas after irritation or trauma is known as the Köbner phenomenon. Patients with psoriasis should also avoid drugs known to worsen the problem (eg, chloroquine, beta-blockers, aspirin or other NSAIDs).

In severe cases, retinoids (acitretin), methotrexate, cyclosporine, 6-thioguanine, azathioprine, a biologic, or hydroxyurea may be used. Retinoids have been reported to cause dry eye, blepharitis, corneal opacities, cataracts, and decreased night vision.^{[28, 29]} All of these may be associated with gastrointestinal intolerance, hepatic damage (acitretin, 6-thioguanine, azathioprine, methotrexate), marrow suppression (6-thioguanine, methotrexate, azathioprine, hydroxyurea) or renal damage (cyclosporine). The use of these systemic medications, with appropriate safety considerations, is supported by Section 4 (2009) of the AAD guidelines.^[23]

In addition, systemic retinoids and hydroxyurea may interfere with proper wound healing and elective procedures, including dental surgery, which are best performed before the start of the medications. Acitretin appears more effective than isotretinoin in psoriasis and does not require enrollment in the IPledge program. On the other hand, there is a 3-year pregnancy prohibition after its use, and many will not use this medication in any patient capable of ever becoming pregnant. Combination therapies, such as a biologic plus another immunosuppressive medication, have been used with good effect but data detailing the safest way to do this are scant. All of the systemic medications except acitretin may increase the risk of infection.

Abruptly stopping steroid therapy in psoriasis or adding known irritant drugs can result in the sudden worsening of psoriasis or appearance of a new form. Commonly, this new form is guttate psoriasis, which is much more severe and cosmetically problematic than the preexisting plaque type. It may also present with a more threatening pustular or erythrodermic psoriatic flare.

The use of biologic agents (proteins with pharmacologic activity) is discussed in Section 1 (2008) and reviewed, with updated safety information, in Section 6 of the AAD guidelines. The AAD recommends a set of baseline laboratory studies before starting treatment with a biologic agent to ensure any underlying conditions or risk factors are understood.^{[21, 25]}

Many of the therapies for psoriasis manipulate the function of the immune system and expose the patient to risk of severe infections while blunting the body’s response. In these patients, findings suggestive of minor infections must be taken seriously, and the risk versus the benefit of continuing the drug in the face of the infection must be weighed.

Keratoconjunctivitis sicca can be treated with ocular lubricants and punctal occlusion. Trichiasis and cicatricial ectropion usually require surgical treatment. Conjunctival, corneal, and anterior chamber inflammation can be treated with topical corticosteroids. Nonsteroidal anti-inflammatory agents or oral corticosteroids are occasionally necessary. Whether systemic immunosuppression is effective for ocular disease is not clear.

Corneal melting, inflammation, and vascularization can be difficult to treat. A bandage contact lens may retard the melting. Topical corticosteroids can control the infiltration and delay the vascularization. In some cases, progression can occur in spite of these treatments and can lead to the need for lamellar or penetrating keratoplasty.

Psoriasis is a chronic problem, and consultation for follow-up with a dermatologist or a rheumatologist is appropriate. Close follow-up is necessary to design an optimal treatment plan in accordance with the severity of disease.

Severity of psoriasis can be classified as follows:

• Mild - Less than 2% of the body is affected
• Moderate - From 3-10% of the body is affected
• Severe - More than 10% of the body is affected

Of note, the palm of the patient’s hand is equal to 1% body surface area.

Determining the severity of psoriasis requires combining objective measures, such as body surface area involvement; disease location; symptoms; and presence of psoriatic arthritis with subjective measures such as the physical, financial, and emotional impact of the disease.

Patients with infectious diseases and psoriasis may be using drugs that modify immunologic response and render them immunocompromised. Investigation into the type of therapy is important and, if such an agent is identified, referral and close follow-up is needed.