Psoriasis treatment choices will be influenced by the amount and location of the psoriasis.
Experience with previous therapy as well as patient preference plays a big part in selecting the most appropriate for each person. Some individuals with minimal disease may be very unhappy with their condition while others with extensive psoriasis seem to accommodate and live relatively unbothered by it. Proximity to treatment centers that offer UV light and day care facilities also influences the options. Patients who have kidney or liver disease will not be good candidates for some of the systemic drugs. Drugs that that you are taking for other diseases must be reviewed to be sure that they do not make your psoriasis worse.
As a general rule, drugs should be used to give maximum benefit but with minimum side-effects. To achieve this, drugs both topical and oral can be combined together or rotated which may not only enhance each others’ effectiveness, but also reduce toxicity by keeping the total dose as low as possible. Topical therapy is a more demanding option as the extent of the psoriasis increases. Some patients even with large surface areas of involvement prefer to avoid oral drugs.
Plaque psoriasis (psoriasis vulgaris)
Available treatment choices:
- Mild corticosteroid
- Potent corticosteroid
- Narrow band (311nm) UVB
Mild/Localized Psoriasis Treatment:
- Try topical therapy first. Single or best combination of a different class of drug.
- Mild steroid alone
- Mild steroid + one of the following: calcipotriol , tazarotene, tar, anthralin.
- Potent steroid in pulses for example, weekends only.
- + one of the following calcipotriol, tazarotene, tar, anthralin.
When your psoriasis is extensive or symptomatic:
- Topical therapy is always the first option to discuss.
- Ultraviolet light is most useful when big surface areas are involved
- UVB has been used for many years. Narrow beam UVB is gaining popularity. Although it takes more time, the side-effects are likely to be less.
- PUVA is effective and gives a longer remission, but there is an increased risk of skin cancer. It is used when UVB has not worked.
- Acitretin can be added to both UVB and PUVA.
- Methotrexate and Cyclosporine are very effective and can be rotated to minimize accumulative side-effects.
- Treat the underlying infection
- It is usually extensive, making topical therapy more difficult. Tars may help some, especially if combined with a topical corticosteroid. An ointment is often used to compound 5-10% LCD (liquor carbonis detergens) with betamethasone 17 valerate 0.1%.
- UVB is the most helpful first treatment. If that is unresponsive then narrow band UVB may work.
- If your psoriasis is difficult and not responding and you are not a woman in the childbearing age range, acitretin can be added.
- If the options above are unsuitable or the patient is unresponsive, PUVA can be used.
- Topical corticosteroids are the most commonly used medications. Care has to be taken to avoid skin atrophy.
- Calcipotriol, tazarotene, anthralin, and tars are usually too irritating.
- Topical tacrolimus is showing promise, probably because of its ability to penetrate the occluded skin.
Palmoplantar Pustulosis of palms and soles:
- Involvement of the palms and soles which does not often respond to topical treatment.
The following systemic drugs are listed in order of preference:
- Acitretin +/- topical PUVA
- (Von Zumbusch) Pustular Psoriasis:
- You need to remove aggravating factors, such as offending drugs, and tars. You must also take care to taper off systemic corticosteroids slowly.
- You will need medical support because of the risk of infection, fluid loss, and loss of body heat.
- You should treat an infection with antibiotics.
- You will probably need systemic drugs to effectively treat this type of psoriasis.
- Acitretin is often a doctor’s first choice. Isotretinoin may be used for younger women
- Cyclosporine and Methotrexate will also help.
In erythrodermic psoriasis, you will see redness and scaling over most of your skin surface.
- When you lose the normal protective functions of your skin, it means that medical support is required to maintain body temperature, and fluid and electrolyte balance. Good nutrition is essential. There is a risk of anemia.
- Be aware that this generalized reaction is often because withdrawal of systemic steroids or potent topical corticosteroids were withdrawn too quickly. Infections or burns from phototherapy can also initiate this generalized response.
- Bed Rest is essential.
- You should use emollients very frequently.
- You should use only mild topical corticosteroids (for example, hydrocortisone ointment)
- You should be on the look out for infection and shock (record your urine output, BP, and daily weight).
- To control this disease you may require systemic therapy.
- If you are a man you can take acitretin. Start at 25mg and increase if necessary.
- Methotrexate could be initiated at a dose of 15mg weekly. It can be increased.
- Cyclosporine can be given at a dose of 4-5 mg/kg a day.
- Maintenance may be achieved with mild topical steroids and/or careful use of UVB.
- This condition is very difficult to treat. 25% or more will also suffer from a fungal infection.
- A trial of topical corticosteroids especially under occlusion
- Calcipotriol may show some benefit in subungual hyperkerastosis
- Intrelasional triamcinalone 0.1ml of 2-5 mg per ml injected into the nail matrix every 2-4 weeks helps the majority of people with this problem, but in 50% there are quick relapses on stopping.
- 5-fluorouracil 1% twice a day to the nail margins reduces the severity of nail changes in two-thirds of nails over a 3-6 period.
- Systemic therapy can be of benefit.
- Early treatment is recommended to prevent joint destruction.
- Aspirin and nonsteroidal anti-inflammatory drugs are effective in early stages of psoriatic arthritis.
- You can use hydroxychloroquine (Plaquanil) without experiencing a flare of your psoriasis
- Methotrexate can be very beneficial, and may produce long lasting improvement.
- Newer agents such as the TNF blockers (tumor necrosis factors) are very valuable.