Hello everyone! I would like to go more into the different therapies of Psoriasis because we discussed as a group that there could be a lot of options.
UVB for psoriasis
UV therapy is one of the first line therapies available for chronic plaque psoriasis, if available. The type of light that is used to treat psoriasis is UVB phototherapy. There are different types of UVB therapy, narrow-band, broad-band, and laser UVB. Narrow-band phototherapy is the most common light therapy and limits wavelengths used. Broad-band UVB therapy is the oldest form of light therapy and has a wider wavelength. Excimer Laser UVB lastly is for targeting smaller areas. Healthcare professionals use this type of therapy when the psoriasis is affecting less than 5 percent of the body. Some benefits to narrow-band UVB is that the light release a smaller range, making it able to clear psoriasis faster and give longer remissions. This treatment might also be quicker than the other types of UVB treatments. It is estimated that about 75% of people using UVB therapy will develop clear skin.
Psoriasis is characterized as an immune mediated disease that affects both the skin and the joints. This condition may become quite complex and tends to have disabling, chronic effects that are very bothersome for certain patients. Psoriasis can provide many challenges that can disturb a person’s quality of life. However, throughout the years, new products and treatments have been released into the market for this serious and life altering condition.
Some of the symptoms of psoriasis may include itching, redness, flaking of the skin, bleeding, and severe pain. According to the World Health Organization, psoriasis is prevalent among two percent of the population in Europe and North America. Some of the common risk factors that may aggravate this condition include weather conditions, sun exposure, UV radiation, ethnicity, gender, and race. The most common form of psoriasis is plaque psoriasis or "psoriasis vulgaris". This condition usually accounts for 90% of psoriatic cases (Boehncke, 2015). Other types of psoriasis include eruptive psoriasis, inverse psoriasis, pustular psoriasis, palmoplantar, generalized, and erythrodermic. In addition, nail psoriasis can also affect patients with who have this condition.
Some factors that may potentially trigger this condition include constant scratching of the skin, piercings, tattoos, sunburns, cytokines, and chemicals that cause skin irritation (Boehncke, 2015). Psoriasis is usually diagnosed by skin biopsies and is rated using the Psoriasis Area and Severity Index score (PASI). This condition may also require full body examinations and a deeper look into the patient genetics.
There are many different types of medications that can be used for the management and prevention of this disease. Phototherapy is known to be one of the first line treatments, along with biologics and non-pharmacological related treatments- such as self-care. According to UptoDate, “Patients with limited plaque psoriasis can be initially treated with topical corticosteroids and emollients. Alternatives include tar, topical retinoids and topical vitamin D. For facial areas, topical tacrolimus may be used as an alternative or as corticosteroid-sparing agents” (UptoDate). According to this information, improvements can usually be seen within one to two months. In certain cases, combination therapy is recommended and highly recognized with patient adherence. In patients who have contraindication to phototherapy, guidelines recommend medications such as methotrexate, cyclosporin, apremilast, and deucravacitinib. Howvever, the benefits of phototherapy include limited side effects and drug related interactions.
Boehncke, Wolf-Henning, and Michael P Schön. “Psoriasis.” Lancet (London, England) vol. 386,9997 (2015): 983-94. doi:10.1016/S0140-6736(14)61909-7
Zhang, Ping, and Mei X Wu. “A clinical review of phototherapy for psoriasis.” Lasers in medical science vol. 33,1 (2018): 173-180. doi:10.1007/s10103-017-2360-1
UptoDate Data Base:
Psoriasis is a skin condition characterized by numerous clinical manifestations including the formation of plaques (patches of this, red, and scaly skin, dry or cracked skin, itchiness and discomfort, as well as swelling or sore joints. This condition is a chronic disease state that constitutes increased inflammation and the pathogenesis of psoriasis is often connected to genetics that predispose patients to later development. The presence of psoriasis in many patients may lead to the development or exacerbation of comorbidities such as psoriatic arthritis, rheumatoid arthritis, inflammatory bowel disease, and cancer. While psoriasis was initially considered a disorder or disease of the keratinocytes found within the skin, further research and development has shown that the immune system and its response to the body is what instigates & hastens the development of psoriasis. Therefore, research has shown that the most efficacious methods to treat psoriasis would lie in medications that can directly interact with the patient’s immune system to prevent an auto-immune response.
For patients who do not suffer from psoriasis severe enough to warrant biologic use, first-line treatment is often relegated to topical or systemic corticosteroids as well as a vitamin D3 supplement. Such treatment is indicated for mild psoriasis. For moderate psoriasis, systemic methotrexate is recommended due to its immunosuppressive capability. In the case of severe psoriasis, patients may be relegated to more intensive medication therapy that readily targets the root-cause of psoriasis.
Biologics are considered one of the most impactful medications utilized in modern-day treatment of psoriasis. Biologic medications are a class of drugs that consists of large, complex molecules that represent targeted therapy, including monoclonal antibodies and receptor fusion proteins. Monoclonal antibodies are medications that are quickly degraded within the gastro-intestinal tract, leading to rapid inactivation of the medication. Due to this mechanism, biologics must be administered parenterally as an injection to ensure that the drug is able to provide a therapeutic effect without automatic inactivation. One of the many biologic medications utilized in the treatment of psoriasis is known as adalimumab, or more commonly known by its brand name--Humira. Adalimumab is linked to the neutralization of TNF-alpha, preventing it from interacting with its corresponding receptors on cell surfaces. By interfering with the TNF-alpha process, inflammatory cytokines such as IL-6 are prohibited from beginning an inflammatory cascade. In doing so, the mechanism by which psoriasis flare-ups are triggered are then mitigated. Many studies have been conducted regarding the efficacy of Adalimumab and many phase 3 trials have shown that Humira has a far more rapid onset of action in comparison to methotrexate.
Psoriasis is a chronic autoimmune condition that has effects on the skin such as inflammation and scaling. In a patient with psoriasis, skin cells are maturing at a rate 10 times faster than normal. This causes a buildup of skin cells that present themselves as thick patches with silvery scales. These patches can develop to be very thick and red, which sometimes can crack and bleed and be extremely itchy and painful. Usually the lifecycle of a skin cell is one month but in people who have psoriasis, the lifecycle of a skin cell can be just a few days. Because the cycle is shortened so extremely, skin cells are not given a chance to be shed from the body before new ones start growing, resulting in a buildup. Psoriasis scales can develop anywhere on the body but are really common on joints such as the elbows and knees.
There are five types of psoriasis: plaque psoriasis, guttate psoriasis, pustular psoriasis, inverse psoriasis and erythrodermic psoriasis. They differ in the way and areas which they present but ultimately are very similar. The most common type of psoriasis is plaque psoriasis, which presents with whitish silver scales or plaques most commonly found on the elbows, knees, and scalp. There are some prevention strategies that can be taken to prevent flareups. It has been found that smoking tobacco and drinking alcohol can aggravate or cause flareups. Alcohol can be enjoyed in moderation but if a person is in the middle of a flareup, they should abstain from alcohol. People with psoriasis should be very consistent with hydration and moisturization to prevent flareups caused by dry skin. Thick, greasy creams and ointments might even be the most beneficial. Lowering stress levels can prevent flareups. Therapy, exercise, and meditation can all be ways of introducing relaxation into a person’s day.
People with psoriasis should be counseled to treat their skin as they would the skin of a baby. Any type of irritation can cause a flareup and therefore the skin should be protected at all times. Injuries, shaving, bug bites, and even adhesives from bandages can all trigger flareups. Receiving shots or vaccines at your doctor’s office may even cause flareups. Patients may also benefit from allergy testing to see if anything in their diet is worsening or triggering their psoriasis flare ups. For example, gluten, which is a protein found in wheat, has been linked to psoriasis flare ups. Eating a heart healthy diet is also important. Lowering intake of saturated fats, but increasing intake of lean proteins that contain omega-3 fatty acids, such as salmon, can benefit your skin. There are certain trigger foods that cause inflammation and avoiding them might improve symptoms. Red meat, refined sugar, processed food, and dairy products all can be linked to inflammation and worsening of psoriasis.
Lifestyle changes can be the ultimate solution for patients struggling with psoriasis. Patient education is key for prevention and should be a goal of all healthcare providers as well as estheticians dealing with the skin.
· Causes and triggers. (2018). psoriasis.org/about-psoriasis/causes
· Kiraly-Liebendorfer A. (2018). Psoriasis and diet: Researchers examine the relationship between food and disease. psoriasis.org/advance/diet-psoriasis-research
· Mayo Clinic Staff. (2018). Psoriasis. mayoclinic.org/diseases-conditions/psoriasis/symptoms-causes/syc-20355840
· What is psoriasis? (2017). niams.nih.gov/health_info/psoriasis/psoriasis_ff.asp
Guselkumab also known as Tremfya, is a human immunoglobulin G1 lambda monoclonal antibody used for the treatment of plaque psoriasis. It is effective by binding to the p19 subunit of IL-23, however IL-39 also contains this p19 subunit. The mechanism of action of Guselkumab is inhibition of IL-23 signaling. This signal inhibition reduces serum levels of IL-17A, IL-17F, and IL-22. This action inhibits the release of proinflammatory cytokines and chemokines, which alleviates the symptoms of psoriasis. Guselkumab is a subcutaneous injection that should be dosed at 100 mg for the first week, fourth week, and then every eight weeks after. Unlike Stelara, which was previously mentioned, this medication is not approved in pediatric patients. Guselkumab, like many of the other monoclonal antibodies for psoriasis, appears to have efficacy for psoriatic arthritis and its efficacy for this indication is currently being evaluated. The major concerns and side effects of this medication include hypersensitivity to the injection and medication, as well as opportunistic infection, due to the immunosuppressant effect of the drug.
Considered the keystone of topical treatment, topical corticosteroids are widely prescribed for mild to moderate psoriasis( <5% Body Surface Area Involvement) because of their anti-inflammatory, immunosuppressant, and antipruritic properties. Despite extensive use, large randomized control trials and head-to-head comparisons are rather limited. It is interesting to note that in the Cochrane Database System Review with randomized trials comparing treatments against placebo or against vitamin D analogues in people with chronic plaque psoriasis, corticosteroids were non-inferior to vitamin D analogues and are associated with a lower incidence of local adverse events. The standardized mean differences ranging from -0.89 (95% CI -1.06 to -0.72) to -1.56 (95% CI -1.87 to -1.26) for strong and very strong corticosteroids, respectively.
control inflammation and itching
convenient, not messy
mainstay topical treatment modality for psoriasis
less effective with continued use (tachyphylaxis occurs)
withdrawal can produce flare-ups
atrophy, telangiectasia, and striae with continued use after skin returns to normalized state
adrenal suppression possible
Mason AR, Mason J, Cork M, Dooley G, Edwards G. Topical treatments for chronic plaque psoriasis. Cochrane Database Syst Rev 2009;(2):CD005028. Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol 2009;60(4):643-59. Epub 2009 Feb 13
Remicade also known as infliximab is another medication that can be used to treat psoriasis. It is a monoclonal antibody that binds to human tumor necrosis factor alpha (TNFα) and inhibits its activity in vivo. Increased levels of TNFα have been found in patients with psoriasis and by inhibiting its role in the body, the idea is that it should help these patients.The mechanism of action is broad, complex and affects many pathways but it mostly works by blocking pro-inflammatory cytokines. Remicade can also be used to treat numerous other conditions such as crohn’s disease, rheumatoid arthritis, and ulcerative colitis. The dosing for plaque psoriasis, psoriatic arthritis, and pustular psoriasis is 5 mg/kg at 0, 2, and 6 weeks, followed by 5 mg/kg every 8 weeks. Four randomized controlled trials were conducted to provide efficacy and safety data for infliximab. All of these trials used the Psoriasis Area and Severity Index as a measure of outcome to determine efficacy. The target was set at 75 meaning that patients needed to see at least a 75% improvement from baseline scores to reach the favorable outcome. By week 10, every study showed at least 70% of patients reached this threshold regardless of the dose being administered. For some studies that number was as high as 80% suggesting its efficacy in treating psoriasis. It is important to note that patients taking this medication may be more susceptible to infections especially if taken with other immunosuppressants.
Home phototherapy is another treatment option for light therapy as well. A research team from the University Medical Center Utrecht, the University of Groningen, and St. Antonius Hospital compared the safety and efficacy of home phototherapy with standard hospital based phototherapy which is narrow-band UVB phototherapy. 196 people with psoriasis were randomized during the trial to either receive either UVB light therapy at home or at an outpatient site at a hospital. Both groups completed questionnaires that asked about their quality of life and satisfaction with the treatment. The effectiveness was significant in both groups and notably, patients who used home therapy had a significantly lower burden of treatment and greater satisfaction with their therapy. The baseline psoriasis area and severity index score (PASI) and self administered psoriasis area and severity index score (SAPSI) were decreased by 74% and 82% respectively by the home setting patients versus 70% and 79% with outpatient setting patients.
Patients with psoriasis covering more than 5% of the body require more specialized systemic therapies. One such drug is Acitretin. It is a second-generation synthetic retinoid that is reserved for the treatment of moderate to severe psoriasis. It plays a role in adjunctive therapy to other systemic agents to improve efficacy. Using this agent can lower doses and reduce the occurrence of side effects of other agents. There are not concrete clinical data or trials studying to support using it as a monotherapy.
Enhance efficacy when given with phototherapy. It is given as a pretreatment for 1–3 weeks prior to PUVA phototherapy session to escalate the response rate. Also for patients who fail to respond to UVB with anthralin or tar
less hepatotoxic than methotrexate (can be an option for patient who cannot take methotrexate)
Side effects such as "mucocutaneous dryness, arthralgia, gastrointestinal upset, and photosensitivity"
Potent teratogen. Women of childbearing age are recommended not to get pregnant 3 years after stopping
Contraindicated with liver or renal dysfunction
Increases triglyceride levels
Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol 2009;61(3):451-85.
Lebwohl M, Drake L, Menter A, Koo J, Gottlieb AB, Zanolli M, et al. Consensus conference: acitretin in combination with UVB or PUVA in the treatment of psoriasis. J Am Acad Dermatol 2001;45(4):544-53
Another therapy is the Vitamin D3 analogues (Calcipotriol). It is a first-line topical agent for the treatment of plaque psoriasis and moderately severe scalp psoriasis. It decreases symptoms by "modulating keratinocyte proliferation and differentiation, and by inhibiting T lymphocyte activity". There was a quantitative systematic review of 37 randomized controlled trials with 6038 patients to evaluate the comparative efficacy and tolerability of topical calcipotriol in the treatment of mild to moderate chronic plaque psoriasis. The researchers concluded that calcipotriol to be safe and efficacious for patients with mild plaque psoriasis and not inferior to most corticosteroids with respect to efficacy. However, this agent does come with side effects such as mild irritant dermatitis and more uncommonly, hypercalcemia with prolonged use. It is important to note that calcipotriol cannot be concomitantly used with lipophilic monohydroxybenzoic acid such salicylic acid or before phototherapy.
Kim, W. B., Jerome, D., & Yeung, J. (2017). Diagnosis and management of psoriasis.Canadian family physician Medecin de famille canadien,63(4), 278–285.
Ashcroft DM, Po AL, Williams HC, Griffiths CE. Systematic review of comparative efficacy and tolerability of calcipotriol in treating chronic plaque psoriasis. BMJ 2000;320(7240):963-7.
A relatively new medication that has been used for psoriasis is SIILIQ. SILIQ also known as brodalumab is a biologic medication for patients with moderate to severe plaque psoriasis indicated for patients who are candidates for systemic therapy or phototherapy and have failed to respond to other systemic therapies. It is a human interleukin-17 receptor A antagonist that works by blocking cytokine responses and preventing the release of pro-inflammatory chemokines precipitating psoriasis. The recommended dose of SILIQ is 210 mg SQ every week for 3 weeks followed by 210 mg every 2 weeks. If there is not an adequate response after 12-16 weeks the medication should be discontinued. This medication was approved based on multiple trials that included 2915 patients in four different countries. These clinical trials showed that brodalumab was better than the placebo in improving symptoms and maintaining this level for an entire year. Some serious side effects of this medication include suicidal thoughts/behavior and infections. Because of the nature of this medication and the suicidal risk, patients need to enroll in the SILIQ REMS Program.
Another option is PUVA which is psoralen plus ultraviolet A therapy. This involves the skin being exposed to UVA light as well as using a medication called psoralen as well. The medication helps the skin react better to the UVA light and makes the therapy more effective. Psoralen is available as a tablet, gel or cream. Topical PUVA is when you apply either as a lotion or soaking in a bath. Oral PUVA is taken as a tablet and is helpful is a patient has thick plaques. The therapy treatment can last between 4 weeks to 3 months. Some possible side effects of UV light therapy could be dry and itchy skin, cold sores, or red patches. These can be treated by applying moisturizer to the skin after the treatment or sunscreen before the treatment. Nausea and vomiting can occur when taking psoralen for PUVA therapy as well, but you can take this medicine as a bath solution instead. Light therapy is shown to have promising effects. In about 50 to 90 out of 100 people, it is shown to have improved symptoms.
Ustekinumab, also known as Stelara, is a human monoclonal antibody, which targets interleukin 12 and 23. Ustekinumab is indicated for the treatment of adults and children 12 years and up that have moderate to severe psoriasis. Ustekinumab by inhibiting IL-12 and IL-23, the autoimmune response that causes the effects of psoriasis are prevented. The biological responses affected include the proinflammatory cytokines; natural killer (NK) cell activation, CD4+ T-cell differentiation and activation. Ustekinumab also interferes with the expression of monocyte chemotactic protein-1, tumor necrosis factor-alpha, interferon-inducible protein-10, and interleukin-8. These patients must also be candidates for phototherapy or systemic therapy. Ustekinumab is a subcutaneous injection and the dosing is weight based. The dosing for adults ≤100 kg is 45 mg on the first week, fourth week and every 12 weeks thereafter. For adults who weigh more than 100 kg, A dose of 90 mg is given with same regimen. As for pediatric patients less than 60 kg, the initial dose is 0.75 mg/kg for the first week, fourth weeks, followed by a maintenance dose of 0.75 mg/kg every 12 weeks after. For pediatric patients between ≥60 to ≤100 kg, the initial dose is 45 mg with the same time regimen. Patients greater than 100kg should receive 90 mg with the same time regimen.
Excimer laser therapy is a special type of therapy that is for specific parts of the skin. It can administer higher doses of UVB. Some side effects include blistering, burns, and pigment changes. Compared to the narrow band UV therapy, the excimer laser therapy has shown to give less number of treatment sessions and smaller UVB exposure to the patient. This reduces a skin cancer risk to the patient and gives a great benefit to this therapy. Some types of psoriasis which excimer laser therapy is great for is scalp, nail, palmoplantar psoriasis. This therapy is also beneficial in combination with other medications such as clobetasol propionate spray and calcitriol ointment.
Another therapy that we mentioned in our review was methotrexate. It is an inhibitor of folate biosynthesis. Its cytostatic and anti-inflammatory properties are used for mild to sever psoriasis. The initial thoughts on how treatment was effective centered around the antiproliferative effects of methotrexate on DNA synthesis in epidermal cells. Evidence supports the concept that it is the immunosuppressive effects on activated T cells that controls psoriasis. Methotrexate is usually given once weekly, which is similar to rheumatoid arthritis. Methotrexate can be given either by oral, intravenous, intramuscular, or subcutaneous. Methotrexate is dosed between 7.5 and 25 mg per week. Initial treatment usually begins at 10 to 15 mg weekly. Patients with impaired renal function, usually elderly patients can be given a single test dose of 5 mg followed by blood work one week later. The dose can be titrated up and the patient can be closely monitored for toxicity. The dose can be escalated every four to eight weeks depending on the patient’s tolerance, efficacy, and toxicity. Methotrexate can