eMedicine Specialties > Emergency Medicine > Dermatology
Psoriasis: Treatment & Medication
Updated: Apr 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Emergency Department Care
- 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.
- Solar or ultraviolet radiation may be helpful.
- Oatmeal baths may be helpful.
Consultations
Psoriasis is a chronic problem, and consultation for follow-up with a dermatologist or rheumatologist is appropriate.
- 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. Close follow up is necessary to design an optimal treatment plan in accordance with the severity of 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.
Medication
Many drugs that affect the rate of production of skin cells 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 UVB light, psoralen with UVA light retinoids (eg, isotretinoin [Accutane], acitretin [Soriatane]), methotrexate (particularly for arthritis), cyclosporine (Neoral, Sandimmune), infliximab (Remicade), etanercept (Enbrel), adalimumab (Humira), and alefacept (Amevive).
Topical corticosteroids
These agents are used to reduce plaque formation. These agents have anti-inflammatory effects and may cause profound and varied metabolic activities. In addition, these agents modify the body's immune response to diverse stimuli.
Triamcinolone acetonide (Aristocort, Kenalog) 0.1% cream
Treats inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Has mild potency and is the first DOC for most patients.
Adult
Apply a thin film bid/tid to lesions daily after bathing, since moist skin absorbs the drug better; continue until a satisfactory response is obtained
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in patients diagnosed with decreased skin circulation; may cause thinning of skin, striae, increased ocular pressure, and tachyphylaxis
Betamethasone dipropionate (Diprolene, Diprosone), 0.05% cream
Treats inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Is a potent topical steroid and is DOC if psoriasis is resistant to milder forms.
Adult
Apply a thin film bid/qid until a favorable response is obtained
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; treatment of rosacea; paronychia; cellulitis; impetigo; angular cheilitis; erythrasma; erysipelas; perioral dermatitis; acne
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in patients diagnosed with decreased skin circulation; can cause atrophic changes in certain areas of body, such as the groin, face, and axillae; if an infection develops, treat with an antifungal or antibacterial agent; if there is no satisfactory response, discontinue the corticosteroid until infection has been controlled; do not use topical corticosteroids as a monotherapy in the treatment of widespread plaque psoriasis
Coal tar
Coal tar is an inexpensive treatment that is available over the counter in shampoos or lotions 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.
Coal tar 1-10% (DHS Tar, Doctar, Theraplex T)
Antipruritic and antibacterial that inhibits deregulated epidermal proliferation and dermal infiltration. Does not injure the normal skin when applied widely and enhances the usefulness of phototherapy. Generally is used as a second-line drug therapy due to messy application, except for shampoos, which may be used and rinsed at once.
Adult
Rub a copious amount of shampoo into the wet hair and scalp or skin and rinse thoroughly; repeat the treatment, leave on for 5 min, and rinse thoroughly
Frequency varies depending on the manufacturer's instructions; may use from qd to twice a week; for severe psoriasis, use daily
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; acute inflammation or open lesions
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Do not apply to eyes; if irritation develops or response is unsatisfactory, discontinue use
Keratolytic agents
This agent is used to remove scale, to smooth the skin, and to treat hyperkeratosis.
Anthralin 0.1-1% (Drithocreme, Anthra-Derm)
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 DOC due to irritation problems of normal skin surrounding lesions and staining of the skin.
Adult
Use sparingly and apply gently and carefully to psoriatic lesions only daily; to avoid unnecessary staining of clothing, do not apply excessive amounts
Pediatric
Not established
Allow an interval of at least 1 week between the discontinuation of corticosteroids and the initiation of anthralin therapy; this reduces complications resulting from the rebound phenomenon caused by long-term use of corticosteroids and withdrawal of corticosteroid treatment
Documented hypersensitivity; acutely or actively swollen psoriatic lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with renal disease; do not apply the treatment to the face or genitalia, and avoid eye contact; if redness develops, discontinue application
Vitamin D-3 analogs
These agents are used in patients with lesions resistant to older therapy or with lesions on the face or exposed areas where thinning of the skin would pose cosmetic problems.
Calcipotriene (Dovonex)
A synthetic vitamin D-3 analog that regulates skin cell production and development. It is used in the treatment of moderate plaque psoriasis. This new treatment does not cause long-term skin thinning or systemic effects. It is more expensive than steroids.
Adult
Apply a thin film bid to the affected skin only until a favorable response
Pediatric
Not established
None reported with the topical use
Documented hypersensitivity; hypercalcemia; vitamin D toxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The lesions and surrounding uninvolved skin may be irritated following treatment; if this happens, discontinue treatment; it may transiently but reversibly elevate serum calcium level; discontinue if increase is outside the normal range
Calcipotriene and betamethasone topical ointment (Taclonex)
Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. 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. Available as a topical ointment containing calcipotriene 0.005% and betamethasone dipropionate 0.064%. Indicated for psoriasis vulgaris.
Adult
Apply to affected area qd; not to exceed 100 g/wk; do not use >4 wk
Pediatric
<18 years: Not established
>18 years: Apply as in adults
Coadministration with other corticosteroids may increase toxicity
Documented hypersensitivity; known or suspected calcium metabolism disorders; erythrodermic, exfoliative, or pustular psoriasis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause hypercalcemia; systemic absorption of topical corticosteroids has caused HPA-axis suppression, Cushing syndrome manifestations, hyperglycemia, and glucosuria; not for prolonged use (ie, >4 wk), large surface areas (ie, >30% of body surface area), or application with occlusive dressings; do not use on face, eyes, axillae, or groin; may cause contact dermatitis
Topical retinoids
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 0.05% and 0.1%
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. May be the DOC for those with facial lesions who are not at risk of pregnancy.
Adult
Apply a thin film qd only to cover no more than 20% of body surface area; use enough (2 mg/cm2) to cover the lesion(s)
Pediatric
<12 years: Not established
>12 years: Apply as in adults
None reported
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May cause a feeling of burning or stinging; discontinue treatment if irritation is excessive; avoid contact with eyes, eyelids, and mouth; rinse thoroughly with water if contact with eyes occurs; retinoids on eczematous skin may cause severe irritation and should not be used; caution patients to take protective measures against exposure to ultraviolet light or sunlight, since photosensitivity may result
Antimetabolites
These agents inhibit cell growth and proliferation.
Methotrexate (Trexall)
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.
Adult
10-25 mg PO/IM qwk; alternatively, 2.5-7.5 mg PO q12h for 3 doses/wk; once optimal clinical response reached, reduce dosage to lowest effective dose; maximum 30 mg/wk; give with folic acid 1 mg/d or leucovorin 5 mg/wk
Pediatric
0.2-0.7 mg/kg/wk PO/IM; escalate dose by 1.25-5 mg/wk until therapeutic effect reached; then taper to beneficial maintenance dose
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral methotrexate (MTX); charcoal lowers MTX levels; coadministration with etretinate may increase hepatotoxicity of MTX; folic acid or its derivatives contained in some vitamins may decrease response to MTX
Probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, can increase MTX plasma levels; may decrease phenytoin plasma levels; may increase plasma levels of thiopurines
Documented hypersensitivity to drug; breastfeeding, alcoholism, liver disease, immunodeficiency, bone marrow hypoplasia, leukopenia, thrombocytopenia or significant anemia
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Avoid conception at least 3 months after therapy, for males, and at least one ovulatory cycle after therapy, for females; monitor CBCs monthly, and liver and renal function q1-3mo during therapy (monitor more frequently during initial dosing, dose adjustments, or when risk of elevated MTX levels, eg, dehydration); MTX has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood counts occur; fatal reactions reported when administered concurrently with NSAIDs
Immunomodulators
These agents regulate key factors responsible for inflammatory response.
Cyclosporine (Sandimmune)
An 11-amino acid cyclic peptide and natural product of fungi. Acts on T-cell replication and activity.
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 G0 or G1 phase of cell cycle suggested.
Binds to cyclophilin, an intracellular protein, which, in turn, prevents formation of interleukin 2 and the subsequent recruitment of activated T cells.
Has about 30% bioavailability, but there is marked interindividual variability. Specifically inhibits T-lymphocyte function with minimal activity against B cells. Maximum suppression of T-lymphocyte proliferation requires that drug be present during first 24 h of antigenic exposure.
Suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions (eg, delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft-vs-host disease) for a variety of organs.
Used in extensive disease refractory to other treatments. Remission is rapid with this therapy; however, skin lesions tend to recur within days to weeks after treatment is stopped.
Maintenance therapy usually is required with lower doses of this drug.
Adult
2.5 mg/kg/d PO divided bid; increase by 0.5 mg/kg/d q2wk after 4 wk if response insufficient; once adequate response achieved, taper dose to lowest effective dose for maintenance; 4 mg/kg/d maximum; discontinue if inadequate response after 6 wk on maximum dose; treatment >1 year not recommended; best to treat for 3-4 mo at a time
Pediatric
Not recommended
Carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease cyclosporine concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase cyclosporine toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin; methylprednisolone and cyclosporine mutually inhibit one another resulting in increased plasma levels of each drug
Documented hypersensitivity; uncontrolled hypertension or malignancies; do not administer concomitantly with PUVA or UVB radiation in psoriasis since it may increase risk of cancer
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Evaluate renal and liver functions often by measuring BUN, serum creatinine, serum bilirubin, and liver enzyme levels; may increase risk of infection and lymphoma; reserve IV use only for those who cannot take PO
Alefacept (Amevive)
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. Indicated for moderate to severe psoriasis.
Adult
7.5 mg IV qwk for 12 wk; alternatively 15 mg IM qwk for 12 wk; may repeat 12-wk regimen if CD4+ T-lymphocyte counts are within reference range and a minimum of 12 wk has passed since the first course
Pediatric
Not established
Administration with other immunosuppressive agents (eg, corticosteroids, cyclosporine) may cause excessive immunosuppression; concurrent administration with live vaccinations may increase risk of disseminated infection
Documented hypersensitivity; administration with additional immunosuppressive agents; individuals infected with HIV (CD4<250); serious infection, concurrent phototherapy treatment, systemic malignancy history
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May increase risk of malignancy or infection (ie, tuberculosis); may cause anaphylaxis or angioedema; may cause induration, inflammation, bleeding, or edema at injection site; reduces CD4+ T lymphocyte counts
Efalizumab (Raptiva)
Recombinant humanized monoclonal IgG1 antibody directed against LFA-1, which interferes with T-lymphocyte activation, trans tissue trafficking and T-lymphocyte reactivation. Used to treat moderate-to-severe plaque psoriasis.
Efalizumab (Raptiva), a drug indicated for psoriasis, is being withdrawn from the US market and will no longer be available after June 8, 2009, because of potential risk for progressive multifocal leukoencephalopathy (PML). PML is a rapidly progressive infection of the central nervous system caused by the JC virus that leads to death or severe disability. Demyelination associated with PML is a result from the JC virus infection. JC virus belongs to the genus Polyomavirus of the Papovaviridae. PML should be considered in any patient presenting with new-onset neurologic manifestations who have taken efalizumab. For more information, see the Food and Drug Administration MedWatch Safety Alert.
Adult
0.7 mg/kg SC first dose followed by 1 mg/kg/wk SC
Pediatric
Not established
Concurrent administration of live vaccinations may increase risk of disseminated infection; administration with other immunosuppressive agents (eg, corticosteroids, cyclosporine) may cause excessive immunosuppression
Documented hypersensitivity; thrombocytopenia; concomitant immunosuppressant use; serious infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Associated with increased risk for life-threatening infections, such as JC virus, resulting in, progressive multifocal leukoencephalopathy, bacterial sepsis, viral meningitis, invasive fungal disease; flulike symptoms may occur (transient); adverse effects may include thrombocytopenia, hemolytic anemia, pancytopenia, peripheral demyelination; patients may experience rebound effects with abrupt cessation of drug (rarely)
Tumor Necrosis Factor Inhibitors
These agents neutralize the effects of TNF-alpha.
Infliximab (Remicade)
A chimeric antibody that binds both the soluble and transmembrane TNF-alpha molecules, thereby neutralizing the effects of TNF-alpha. Indicated for severe psoriasis and moderate-to-severe psoriatic arthritis. Screen patients for TB and hepatitis B as reactivation of both illnesses is associated with TNF-alpha inhibitors.
Adult
5 mg/kg IV infusion at 0, 2, and 6 wks as induction regimen, then 5 mg/kg q6-8wk for maintenance
IV infusion must be administered over at least 2 h; must use infusion set with in-line, sterile, nonpyrogenic, low-protein-binding filter (pore size <1.2 microns)
Pediatric
Not established
Concurrent administration of live vaccinations may increase risk of disseminated infection; administration with other immunosuppressive agents (eg, corticosteroids, cyclosporine) may cause excessive immunosuppression
Documented hypersensitivity; active serious infections; NYHA class III-IV CHF; concurrent live vaccinations
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Incidence of serum sickness may be decreased with concomitant infusion of methotrexate; may increase risk of malignancy or infection (ie, tuberculosis); reversible conditions of lupus may occur without renal or CNS complications, cytopenia, MS, and exacerbation of CHF are also associated with use of this drug; may be associated with nonmelanoma skin cancers
Etanercept (Enbrel)
A recombinant human TNF-alpha receptor protein fused with Fc portion of IgG1 that binds to soluble and membrane bout TNF-alpha, thereby neutralizing the effects of TNF-alpha. 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-alpha inhibitors.
Adult
50 mg SC 2 times/wk for 3 mo followed by 50 mg once qwk
Pediatric
<4 years: Not established
4-17 years of age: 0.8 mg/kg SC once qwk; 50 mg/dose maximum
>17 years: Administer as in adults
Concurrent administration of live vaccinations may increase risk of disseminated infection; administration with other immunosuppressive agents (eg, corticosteroids, cyclosporine) may cause excessive immunosuppression
Documented hypersensitivity; sepsis; concurrent live vaccination
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May increase risk of malignancy or infection (ie, tuberculosis); mildly pruritic injection site reactions occur; reversible conditions such as lupus without renal or CNS complications, cytopenia, MS, and exacerbation of CHF may occur
Adalimumab (Humira)
Fully human anti-TNF-alpha monoclonal antibody. Binds specifically to soluble and membrane bound TNF – alpha. Thereby neutralizing the effects of TNF-alpha. 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-alpha inhibitors.
Adult
80 mg SC the first wk; 40 mg SC the second wk, followed by 40 mg SC every other wk
Pediatric
Not established
Concurrent administration of live vaccinations may increase risk of disseminated infection; administration with other immunosuppressive agents (eg, corticosteroids, cyclosporine) may cause excessive immunosuppression
Documented hypersensitivity to drug; active serious infections; NYHA class III-IV CHF; concurrent live vaccinations
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May experience moderately painful injection site reactions; rare cases of serious infections (ie, tuberculosis) and malignancies and reversible conditions of lupus without renal or CNS complications, cytopenia, MS, and exacerbation of CHF may occur
More on Psoriasis |
| Overview: Psoriasis |
| Differential Diagnoses & Workup: Psoriasis |
 Treatment & Medication: Psoriasis |
| Follow-up: Psoriasis |
| Multimedia: Psoriasis |
| References |
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Further Reading
Keywords
psoriasis, skin itching, itchy skin, scaly skin, psoriasis treatment, psoriasis symptoms, discoid psoriasis, plaque psoriasis, guttate psoriasis, skin disorder, skin lesions, oral psoriasis, nail psoriasis, psoriatic arthritis, scalp psoriasis, erythrodermic psoriasis, pustular psoriasis, inverse psoriasis
