Psoriasis is a chronic autoimmune condition characterised by the presence of patches of abnormal skin that are scaly, elevated and itchy. In darker people, the colour of the skin patches may be purple instead of pink. Psoriasis was initially thought to be primarily a disease of dysfunctional proliferation and differentiation of keratinocytes (the layer of cells that proliferates to form the surface of the skin). However, it is now widely recognised that additional roles are being played by T helper (Th)1 and Th17 lymphocytes in the formation of the disease, through the release of inflammatory cytokines that promotes further recruitment of immune cells, keratinocyte proliferation, and sustained chronic inflammation. Beyond the physical dimensions of the disease, psoriasis has an extensive emotional and psychosocial effect on patients, affecting social functioning and interpersonal relationships. As a disease of systemic inflammation, psoriasis is associated with multiple comorbidities, including cardiovascular disease and malignancy. This article will discuss the current management of Psoriasis that is divided into two – topical agents and systemic therapy.
Topical therapy refers to treatment or medication that is applied on the exterior surface/the skin. Below are the current management of Psoriasis in the form of topical agent.
- Corticosteroids: The first in the list of current management of Psoriasis is none other than Corticosteroid – considered to be the cornerstone of topical treatment, corticosteroids are often well tolerated and effective for patients with mild psoriasis. Overall, topical steroids, in its various formulations, strengths, and combinations are efficacious as an initial therapy for the rapid control of symptoms of Psoriasis. The effect of corticosteroid can also be augmented when used in combination with other form of medication – for instance, salicylic acid, a keratolytic agent, can be combined with steroid therapy to help treat plaques with thicker scales, for better penetration of medication. It is worth noting that although uncommon, the long-term use of topical corticosteroid may lead to possible complication such as local skin changes, tachyphylaxis (rapid and short-term onset of drug tolerance), and conditions associated with hypothalamic-pituitary-adrenal axis suppression.
- Vitamin D3 analogues: Calcipotriol is a synthetic version of calcitriol (vitamin D3) and it is the first-line topical agent for the treatment of plaque psoriasis and moderately severe scalp psoriasis. It reduces symptoms by modulating keratinocyte proliferation and differentiation, and by inhibiting T lymphocyte activity. Multiple randomized controlled trials (RCTs) have shown calcipotriol to be safe and efficacious for patients with mild plaque psoriasis and not inferior to most corticosteroids with respect to efficacy. Furthermore, a Cochrane meta-analysis of 177 RCTs showed that vitamin D3 analogues are more effective than all other topical medications (with the exception of the most potent topical agent – corticosteroids) Given their efficacy and safety profile, vitamin D3 analogues are commonly used as monotherapy (single therapy) or, more often, in combination with other medications. Side effects include mild irritant dermatitis and rarely, hypercalcemia (with excessive use). These agents should not be used in combination with salicylic acid or before phototherapy.
- Combination products: Combination of calcipotriol (Vitamin D3 analogue) and betamethasone dipropionate (Corticosteroid) was shown to be more effective for psoriasis than either monotherapy alone in a Cochrane review of 177 RCTs. Furthermore, it is also found that when used in combination or sequentially, incidence of adverse events is reduced. Moreover, based on a systematic review of 6 RCTs with 6050 patients, the mean reduction in Psoriasis Area and Severity Index score at 4 weeks was 74% with combination therapy, compared to 59% and 63% with calcipotriol and betamethasone dipropionate, alone, respectively. The combined preparation is well tolerated and can be applied once daily, avoiding the facial, genital, and flexural areas. In the current management of Psoriasis with regards to topical agents, this is the most efficacious form of topical treatment.
- Phototherapy: Phototherapy is a mainstay treatment of moderate to severe psoriasis, especially in psoriasis that is unresponsive to topical agents. It is available in a few bands but as shown in multiple RCTs, Narrowband-UVB therapy is often used as first-line treatment owing to its efficacy and safety advantages. In fact, NB-UVB therapy can be given to almost any patient, including children and pregnant women. However, the issue with phototherapy despite its safety is the limited availability of phototherapy centres and the need for frequent visits (3 times a week for 3 months initially), rendering this option rather inconvenient for patients.
- Acitretin: Acitretin is a synthetic retinoid indicated for the treatment of moderate to severe psoriasis. Its role as an adjunctive therapy to other systemic agents has been well documented to enhance efficacy, lower doses, and reduce occurrence of side effects. However, common side effects of Acitretin include mucocutaneous dryness (dryness of the mucous membrane and skin), arthralgia (joint pain), gastrointestinal upset, and photosensitivity. This medication can sometimes cause transaminitis (inflammation of the liver that leads to the elevation of certain liver enzymes) and elevated triglyceride levels. Acitretin is also a potent teratogen (substance that can cause birth defects) and therefore should be avoided in women of childbearing age and potential; it is recommended that women not get pregnant for 3 years after discontinuing the medication.
- Methotrexate: Methotrexate is an inhibitor of folate biosynthesis, used for its cytostatic and anti-inflammatory properties in the treatment of moderately severe to severe psoriasis, as well as psoriatic arthritis. A well-known side effect is hepatotoxicity followed by other also common side effects such as nausea, vomiting, diarrhea, and fatigue. It is also a teratogen as it can cause intrauterine fetal death and/or congenital anomalies when administered to pregnant women. In women of reproductive potential, methotrexate use is not recommended unless the benefits of therapy are expected to outweigh the considered risks, and when it is used, counselling on its effect towards pregnancy should be adequately given.
- Cyclosporine: Cyclosporine is a calcineurin inhibitor indicated for the treatment of moderate to severe psoriasis. There is also evidence for its efficacy in psoriatic arthritis. It has been shown in a study involving 400 patients, to cause significant improvement or complete remission in 80% to 90% of patients within 12 to 16 weeks. Advantages over other systemic agents include rapid onset of action and less concern about myelosuppression (Bone marrow suppression) or hepatotoxicity (toxic to the liver). Adverse effects include nephrotoxicity (kidney toxicity), hypertension, elevated triglyceride levels, gingival hyperplasia, electrolyte disturbance and malignancies such as skin cancers and lymphoma.
- Biologic therapy: The last treatment option in this list of current management of Psoriasis is Biologics. Biologics have emerged as a highly potent treatment options in patients for whom traditional systemic therapies fail to achieve an adequate response, are not tolerated owing to adverse effects, or are unsuitable owing to comorbidities. Studies suggests that infliximab might be the most efficacious, followed by ustekinumab, adalimumab, and etanercept. Choice of therapy depends on clinical needs, benefits and risks, patient preferences, and cost effectiveness.
The above options are the current management of Psoriasis but please consult your doctor to decide what is the best treatment suited for you and your needs.
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