CUSTOM DERMATOLOGY SEARCH:
New Systemic Treatments for Psoriasis
S. Pirzada, MD1; Z. Tomi, MD, FRCPC2; W. Gulliver, MD, FRCPC2,3
Psoriasis is a chronic, immune-mediated disease, affecting more than 1 million adults in Canada with more than 250,000 new cases diagnosed each year in North America.[Gupta AK, et al. J Cutan Med Surg 8 Suppl:3-7 (2004 Aug).] Up to 35% of people with psoriasis have moderate-to-severe disease, affecting 2%–10% of total body surface area.[Thomas VD, et al. J Am Acad Dermatol 53(2):346-51 (2005 Aug).] Up to 30% of Canadians with psoriasis develop psoriatic arthritis (PsA), [The Arthritis Society. Psoriatic Arthritis. URL: http://www.arthritis.ca/types%20of%20arthritis/psoriatic%20arthritis/default. asp?s=1.] and half of those with PsA are estimated to have already experienced serious joint damage (e.g., bone loss) upon first diagnosis. As this can lead to progressive and often irreversible bone and joint destruction, early diagnosis is important to prevent long-term effects. The need for effective and safer therapies has been increasing as more studies show the serious psychosocial and sometimes debilitating effects of moderate-to-severe psoriasis. However, even psoriasis confined to palms or soles, although covering a small area, can cause difficulty for patients.
Standard Systemic Therapies for Psoriasis
The standard systemic therapies for psoriasis are methotrexate, cyclosporine, oral retinoids such as acitretin (Soriatane®), psoralen + UVA (PUVA), and retinoid PUVA (RePUVA). Less commonly used therapies are hydroxyurea (Hydrea®) and mycophenolate mofetil (CellCept®).
New Systemic Therapies for Psoriasis
Biologics are new systemic therapies that have given dermatologists and rheumatologists a new tool to treat psoriasis, with several undergoing clinical trials in Canada, the US, and Europe. Biologics are immunomodulators and bioengineered proteins (such as antibodies, fusion proteins, or recombinant cytokines) that target the pathological effects of T cells directly. Targeted biologic therapies are designed to:
Biologics approved by the US FDA and Health Canada to treat psoriasis and psoriatic arthritis (PsA) are infliximab (Remicade®) and etanercept (Enbrel®). Efalizumab (Raptiva®) and alefacept (Amevive®) are indicated only for psoriasis, and adalimumab (Humira®) is currently approved for PsA only. The availability of biologics has brought about a shift in the treatment approach to psoriasis. In the past, a more stepwise approach was used with a topical being prescribed first and then moving to UV light and/ or systemic drugs. Now the trend is to use the most effective treatment early in the course of the disease. In 2005, Canadian Consensus Guidelines were published recommending that all appropriate treatment options, including biologic agents, be considered together, and a patient’s specific characteristics and needs be taken into account.[Guenther L, et al. J Cutan Med Surg 8(5):321-37 (2004 Sep-Oct).] The choice of treatment should depend on the severity of the psoriasis and its impact on the patient’s quality of life. AntiTNF drugs are particularly effective for treating PsA.
Infliximab (Remicade®)[Infliximab (Remicade®) Package Insert. Centocor, Inc., Malvern, PA (2002).]
Etanercept (Enbrel®)[Etanercept (Enbrel) Package Insert. Immunex Corp., Seattle, WA (2004).]
Efalizumab (Raptiva®)[Thomas VD, et al. J Am Acad Dermatol 53(2):346-51 (2005 Aug).]
Alefacept (Amevive®)[Thomas VD, et al. J Am Acad Dermatol 53(2):346-51 (2005 Aug).]
Biologics are one of the more effective and relatively safe options for long-term control of psoriasis. They have reduced the time needed to clear the signs of chronic disease, and are effective in maintaining a disease-free state for longer durations. Biologics can safely be used with other treatment modalities (i.e., methotrexate, cyclosporine, acitretin and hydroxyurea). Clinicians should assess patients’ psoriasis and their psychosocial and quality of life issues, before deciding on the optimum treatment modality. With the availability of biologics, all treatment options should be considered equally.
Dermatologic Diagnostic Challenge
Question: A 32 year-old female presented in the summer with a pruritic bullous eruption on bilateral dorsal feet of 2 weeks’ duration. She is a nurse who is regularly in contact with patients. She is otherwise healthy, although a recent ankle sprain resulted in a prescription for a topical nonsteroidal anti-inflammatory medication.
What is the diagnosis?
Go online to www.SkinTherapyLetter.ca/cases to view an image and learn the answer.
Case study submitted by Benjamin Barankin, MD, Toronto, Canada
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Last modified: Thursday, 20-Feb-2014 17:05:41 MST