Psoriasis

Description

Alternative Names

Treatment

Many medications used topically (on the skin) or orally are available for the treatment of psoriasis. Many patients require only over-the-counter treatment or even none at all during relapses. About a third of patients with psoriasis, however, do not respond to over-the-counter remedies and lifestyle changes and require aggressive treatments. In some cases, such treatments need to be lifelong.

Treatment Options

In general, the following three treatment options are used for psoriasis, from least to greatest potency:

• Topical Medications. Options include lotions, ointments, creams, and shampoos. These may be useful for mild-to-moderate psoriasis. Topical medicines rarely produce complete clearance, however.
• Phototherapy. Options include light-wave radiation treatments using broad- or narrow band ultraviolet B (UVB) or psoralen with ultraviolet A (PUVA). This therapy is effective for moderate-to-severe psoriasis. Phototherapies are more effective than drugs and have fewer side effects than most systemic agents. Even more promising, in a 2000 analysis comparing a number of psoriasis treatments, an advanced phototherapy called narrow band UVB achieved the highest complete clearance rate (86% of patients).
• Systemic Agents. This treatment employs various oral drugs that affect the whole body system, not just the skin. These agents have significant side effects and are generally reserved for severe psoriasis.
• Controlled comparison studies are needed to determine the safest and most effective treatments. In any case, individual requirements vary widely and treatment selection must be carefully discussed with the physician.

Treatment Sequences

Administering therapies in a specific sequence is a strategy for providing both quick relief of symptoms and long-term maintenance. It involves three main steps:

• The quick fix, to clear the psoriatic lesions during an acute outbreak (e.g., a high-potency topical steroid in mild to moderate psoriasis or an oral immunosuppressant in more severe cases).
• The transitional phase, intended to gradually introduce the maintenance drug.
• Ongoing maintenance therapy.

Choices for transitional or maintenance regimens depend on the severity of the condition. Some examples are described in the following sections.

Rotational Therapy

In severe chronic cases, a physician may recommend rotational therapy. This approach alternates treatments. The goal is to prevent severe side or tolerance effects from prolonged use of a single agent. An example of a rotational schedule may be the following:

• Phototherapy is administered for about two years and stopped.
• One or two powerful systemic drugs are then administered for one or two years and withdrawn.
• Phototherapy is started again, and the cycle is repeated.

Combination Therapies

Combinations of oral agents, topical therapies, and phototherapy are increasingly used rather than single agents. Combinations of oral agents are particularly useful since the doses of each one can be reduced, thereby lowering the risk for severe side effects. Thousands of combinations are possible, and the patient and physician should discuss the most beneficial for individual needs.