Psoriasis Treatment & Management

Management of psoriasis may involve topical and systemic medication, phototherapy, stress reduction, climatotherapy, and various adjuncts such as sunshine, moisturizers, salicylic acid, and other keratolytics such as urea.

Expert dermatologists from across the globe released a consensus report on treatment optimization and transitioning for moderate-to-severe plaque psoriasis. Recommendations of the 2013 consensus report include the following:

• Methotrexate may be used for as long as it remains effective and well-tolerated.

• Cyclosporine is generally used intermittently for inducing a clinical response with one or several courses over a 3–6 month period.

• Transition from conventional systemic therapy to a biological agent may be done directly or with an overlap if transitioning is needed because of lack of efficacy, or with a treatment-free interval if transitioning is needed for safety reasons.

• Combination therapy may be helpful.

• Continuous therapy for patients receiving biologicals is recommended.

• Switching biologicals because of lack of efficacy should be performed without a washout period while switching biologicals for safety reasons may require a treatment-free interval.

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. ^{[6, 39, 40, 41, 42]} 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. ^[42]

A summary of biologic therapy guidelines from the British Association of Dermatologists can be found in Guideline Summary.

Patients with guttate, erythrodermic, or generalized 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. ^[40]

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, tazarotene, salicylic acid, phenolic compounds, and calcipotriene (a vitamin D analog) also may be effective especially when used in combination with topical corticosteroids. 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. ^[43] Oatmeal baths may be helpful for itching.

Solar or therapeutic ultraviolet (UV) radiation may be helpful. Various UV light treatments are used—now most commonly, UVB, although psoralen + UVB (PUVA) is still used. 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. ^[41]

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 intermittent availability issues.

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 (SCC) and possibly malignant melanoma. ^{[39, 41]} A prospective study of 1380 patients found a strong correlation between number of PUVA treatments and risk of developing one or more SCC. According to the study, exposure to more than 350 PUVA treatments greatly increases the risk of SCC. ^[44]

In a retrospective study of 48 patients (mean age, 51 yr; 33 women, 15 men), psoralen-UVA (PUVA) therapy was found to be an appropriate treatment alternative for palmoplantar psoriasis, according to Carrascosa et al. It provided similar response rates to systemic treatment and often with increased tolerance and safety. PUVA was found to be effective in 63% of cases of palmoplantar psoriasis. Systemic therapy, however, was required in 47.9% of patients, with acitretin being the drug most often used. Adverse events occurred in 25% of patients, with the most common one being mild erythema (18%). ^[45]

Narrowband UVB therapy has always been accepted as a good treatment modality of psoriasis, ^[46] and the AAD guidelines recommend it over broad-band (UVB), although both are less effective than PUVA. ^{[39, 41]} As with PUVA, the guidelines also recommend treatment with combinations of UVB and topical or systemic agents. ^[41] However, a study by Keaney and Kirsner gives objective reasoning for the benefit of narrowband 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. ^[10] UVB also has the advantage of not leaving the patient with a prolonged period of photosensitivity as PUVA does.

Guttate 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, so that systemic therapy or intralesional steroids may be best for these. ^[47]  In 2017, the US Food and Drug Administration (FDA) approved the addition of moderate-to-severe fingernail psoriasis data to the adalimumab prescribing information, based on results from a phase 3, multicenter, randomized, double-blind, parallel-arm, placebo-controlled clinical trial. ^[48]

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, when feasible, avoid drugs known to worsen the problem (eg, chloroquine, beta-blockers, aspirin or other NSAIDs). They should also avoid alcohol to excess. An association has been made between nonalcoholic fatty liver disease and moderate-to-severe psoriasis. What is related to treatment and what is related to psoriasis itself is still being studied. ^[49]

In severe cases, systemic medications such as retinoids (acitretin), methotrexate, cyclosporine, 6-thioguanine, azathioprine, a biologic, or hydroxyurea may be necessary for adequate control. Retinoids have been reported to cause dry eye, blepharitis, corneal opacities, cataracts, and decreased night vision. 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 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. ^{[39, 42]} Some patients with chronic hepatitis C may be safely treated with biologic agents, ^[50] while active hepatitis B is still considered a contraindication.

The use of these systemic medications, with appropriate safety considerations, is supported by Section 4 (2009) of the AAD guidelines. ^[6] Increased risk of infection applies to all systemic immune-suppressing medications, especially when used in combinations. 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.

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.

Because of concerns that immune-suppressing medications may blunt the body response to malignancies, most consider active or untreated cancer a contraindication to starting such medications.

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.

Many suggest that because of the comorbidities of heart disease and cardiovascular disease that if adult patients have not been recently evaluated and screened for these, they should either be tested or referred back to their primary care provider to consider what is appropriate for any particular patient.

Patients with psoriasis, especially widespread and severe, have a higher incidence of depression, which may require medical intervention. If this cannot be managed by their primary care provider, referral to a mental health specialist might be appropriate.

Autoimmune diseases are generally associated with increased rates of lymphoma and myelodysplastic disease. Whether this is related to the disease itself or to its treatment is not yet determined. Patients who have laboratory abnormalities or physical findings of hematologic disease or malignancy should be evaluated by a hematologist and/or oncologist as appropriate. ^[51]

No specific surgical treatments are available for psoriasis, other than procedures relating to ophthalmic complications as described in other sections. The development of psoriasis at surgical sites (and after sunburn) is a recognized phenomenon.

See above Treatment of Skin Lesions for a discussion on different treatment options. All newer medications, especially the biologic therapies, are extremely expensive, with cash prices ranging from $30,000 per year to over $80,000 per year. Other medications, topical and systemic, that have been available for decades have been subjected to regular price increases, which, while keeping them less expensive than a newer biologic agent, has still resulted in them being very expensive. This usually includes generic medications, when generics are available.

Industry communications reveal that the list cost of a new medication has little to do with the cost of research and manufacturing expenses, but more to do with target income goals and considerations of what the market will bear. For this reason, most insurance plans do not do blanket approval of any and all FDA-approved medications and will often require a staged approval process, where a patient will have to have been unresponsive or have had significant adverse effects to less expensive medications before more expensive treatments are considered. This is even more problematic when there are attempts to do off-label psoriasis treatment using medications indicated for other inflammatory and arthritic conditions. Such use, even if supported by the scientific literature, is often be branded "experimental", and insurance coverage may be difficult or impossible to obtain.

Difficulty in reliably obtaining, storing, and using some of these newer medications may explain why the biologics seem to be less efficacious in patients with lower socioeconomic status. ^[52]

Ample literature suggests that weight loss can help psoriasis, but other attempts to show improvement with more specific diets, such as a gluten-free diet, are less conclusive. Studies of very-low-calorie diets and the “Mediterranean Diet" have both shown improvement in anecdotal reports and small studies. ^{[53, 54]} Nutritional supplements have shown limited benefit, with the exception of fish oil. ^[55] Vitamin D itself has also been reported to be of benefit in small studies. ^[56] Much more work needs to be done before enthusiastic support of any particular supplement or dietary plan may be offered.

Any restrictions on activity would relate to concomitant arthritis and how well it is being controlled. Natural sunlight can help psoriasis and may explain why it is relatively rare on the face. It has been suggested that a more active lifestyle can help psoriasis, but whether this is an independent factor or more related to better weight control is less certain.

No specific strategies prevent psoriasis, although healthy lifestyles that avoid obesity and reduced alcohol use can make control easier and increase the chances of at least temporary remission. Whenever possible, patients who are currently being treated for psoriasis or have a history of psoriasis should avoid over-the-counter and prescription medications known to exacerbate it. This includes the use of over-the-counter NSAIDs such as ibuprofen and naproxen.

Other than age-appropriate screening for cardiovascular disease, long-term monitoring is generally treatment specific (eg, skin cancer in phototherapy patients, liver disease in methotrexate patients, tuberculosis exposure in patients on biologic medications).

Guidelines on screening for comorbidities in pediatric patients with psoriasis have been issued by the Pediatric Dermatology Research Alliance and National Psoriasis Foundation. ^[57] Features include the following:

• Overweight or obesity - Start at age 2 years; use body mass index criteria

• Type 2 diabetes -Starting at age 10 years or puberty onset in overweight patients with two risk factors, screen every 3 years; screen obese patients every 3 years regardless of risk factors; use fasting serum glucose value for screening

• Dyslipidemia - Start at age 9-11 years and then again at age 17-21 years; use universal lipid screening; fasting lipid panel recommended

• Hypertension - Starting at age 3 years, screen yearly using age, sex, and height reference charts

• Nonalcoholic fatty liver disease (NAFLD) - Starting at age 9-11 years, use alanine aminotransferase in overweight or obese children with risk factors (eg, insulin resistance, prediabetes or diabetes, central adiposity, dyslipidemia, sleep apnea, family history of NAFLD/nonalcoholic steatohepatitis (NASH); consider screening at a younger age if patients have greater risk factors (eg, severe obesity, family history of NAFLD/NASH, hypopituitarism); with normal screening results, repeat alanine aminotransferase screening every 2-3 years based on risk factors (or sooner if they increase in number or severity)

• Polycystic ovary syndrome - Consider screening in patients with symptoms (eg, oligomenorrhea, hirsutism)

• Gastrointestinal disease - Considering evaluating patients with decreased growth rate, unexplained weight loss, or symptoms of inflammatory bowel disease

• Arthritis - Screen periodically with review of systems and physical examination

• Uveitis - Only warranted in psoriatic arthritis.

• Mood disorders and substance abuse - Regardless of age, annually for depression and anxiety; at age 11 years, annually for substance abuse

• Quality of life - Consider using formal instrument (eg, Children's Dermatology Life Quality Index)