PSORIASIS

What is psoriasis?

Psoriasis is a noncontagious skin condition that produces red, dry plaques of thickened skin. The dry flakes and skin scales are thought to result from the rapid proliferation of skin cells that is triggered by abnormal lymphocytes from the blood . Psoriasis commonly affects the skin of the elbows, knees, and scalp.
Some people have such mild psoriasis (small, faint dry skin patches) that they may not even suspect that they have a medical skin condition. Others have very severe psoriasis where virtually their entire body is fully covered with thick, red, scaly skin.
Psoriasis is considered a non-curable, long-term (chronic) skin condition. It has a variable course, periodically improving and worsening. It is not unusual for psoriasis to spontaneously clear for years and stay in remission. Many people note a worsening of their symptoms in the colder winter months.

Psoriasis is seen worldwide, in all races, and both sexes. Although psoriasis can be seen in people of any age, from babies to seniors, most commonly patients are first diagnosed in their early adult years.
Patients with more severe psoriasis may have social embarrassment, job stress, emotional distress, and other personal issues because of the appearance of their skin.

What causes psoriasis?

The exact cause remains unknown. There may be a combination of factors, including genetic predisposition and environmental factors. It is common for psoriasis to be found in members of the same family. The immune system is thought to play a major role. Despite research over the past 30 years looking at many triggers, the "master switch" that turns on psoriasis is still a mystery.

What does psoriasis look like? What are the symptoms and signs?

Psoriasis typically looks like red or pink areas of thickened, raised, and dry skin. It classically affects areas over the elbows, knees, and scalp. Essentially any body area may be involved. It tends to be more common in areas of trauma, repeat rubbing, use, or abrasions.
Psoriasis has many different appearances. It may be small flattened bumps, large thick plaques of raised skin, red patches, and pink mildly dry skin to big flakes of dry skin that flake off.
There are several different types of psoriasis, including psoriasis vulgaris (common type), guttate psoriasis (small, drop like spots), inverse psoriasis (in the folds like of the underarms, navel, and buttocks), and pustular psoriasis (pus-filled, yellowish, small blisters). When the palms and the soles are involved, this is known as palmoplantar psoriasis.
Sometimes pulling of one of these small dry white flakes of skin causes a tiny blood spot on the skin. This is medically referred to as a special diagnostic sign in psoriasis called the Auspitz sign.
Genital lesions, especially on the head of the penis, are common. Psoriasis in moist areas like the navel or area between the buttocks (intergluteal folds) may look like flat red patches. These atypical appearances may be confused with other skin conditions like fungal infections, yeast infections, skin irritation, or bacterial Staph infections.
On the nails, it can look like very small pits (pinpoint depressions or white spots on the nail) or as larger yellowish-brown separations of the nail bed called "oil spots." Nail psoriasis may be confused with and incorrectly diagnosed as a fungal nail infection.
On the scalp, it may look like severe dandruff with dry flakes and red areas of skin. It may be difficult to tell the difference between scalp psoriasis and seborrhea (dandruff). However, the treatment is often very similar for both conditions.
What is the treatment for psoriasis?


There are many effective treatment choices for psoriasis. The best treatment is individually determined by the treating physician and depends, in part, on the type of disease, the severity, and the total body area involved.
For mild disease that involves only small areas of the body (like less than 10% of the total skin surface), topical (skin applied) creams, lotions, and sprays may be very effective and safe to use. Occasionally, a small local injection of steroids directly into a tough or resistant isolated psoriasis plaque may be helpful.
For moderate to severe disease that involves much larger areas of the body (like 20% or more of the total skin surface), topical products may not be effective or practical to apply. These cases may require ultra-violet light treatments or systemic (total body treatments such as pills or injections) medications. Internal medications usually have greater risks.
For psoriatic arthritis, systemic medications are generally required to stop the progression of permanent joint destruction. Topical therapies are not effective.
It is important to keep in mind that as with any medical condition, all medications carry possible side effects. No medication is 100% effective for everyone, and no medication is 100% safe. The decision to use any medication requires thorough consideration and discussion with your physician. The risks and potential benefit of medications have to be considered for each type of psoriasis and the individual patient. Some patients are not bothered at all by their skin symptoms and may not want any treatment. Other patients are bothered by even small patches of psoriasis and want to keep their skin clear. Everyone is different and, therefore, treatment choices also vary depending on the patient's goals and expressed wishes.
An approach to minimize the toxicity of some of these medicines has been commonly called "rotational" therapy. The idea is to change the antipsoriasis drug every six to 24 months in order to minimize the possible side effects from any one type of therapy or medication.
In another example, a patient who has been using strong topical steroids over large areas of their body for prolonged periods may benefit from stopping the steroids for a while and rotating onto a different therapy like calcitriol (Vectical), light therapy, or an injectable biologic.

What creams or lotions are available for psoriasis?

Topical (skin applied) medications include topical corticosteroids, vitamin D analogue creams calcitriol, topical retinoids (Tazorac), moisturizers, topical immunomodulators (tacrolimus and pimecrolimus), coal tar, anthralin, and others.

• Topical corticosteroids (steroids, such as hydrocortisone) are very useful and often the first-line treatment for limited or small areas of psoriasis. These come in many preparations, including sprays, liquid, creams, gels, ointments, and mousses. Steroids come in many different strengths, including stronger ones are used for elbows, knees, and tougher skin areas and milder ones for areas like the face, underarms, and groin. These are usually applied once or twice a day to affected skin areas.
  
  Strong steroid preparations should be limited in use. Overuse or prolonged use may cause problems including potential permanent skin thinning and damage called atrophy.



• A vitamin D analogue cream called calcitriol has also been useful in psoriasis. The advantage of calcitriol is that it is not known to overly thin the skin like topical steroids. It is important to note that this drug is not regular vitamin D and is not the same as taking regular vitamin D or rubbing it on the skin.
  
  A similar drug, calcipotriene, may be used in combination with topical steroids for better results. There is a newer two-in-one combination preparation of calcipotriene and a topical steroid called Taclonex. Results with calcipotriene alone may be slower and less than results achieved with typical topical steroids. Not all patients may respond to calcipotriene as well as to topical steroids.
  
  A special precaution with vitamin D analogue creams is that it should not be used on more than 20% of the skin in one person. Overuse may cause absorption of the drug and an abnormal rise in body calcium levels.



• Moisturizers, especially with therapeutic concentrations of salicylic acid, lactic acid, urea, and glycolic acid may be helpful in psoriasis. These moisturizers are available as prescription and nonprescription forms. These help moisten and lessen the appearance of thickened psoriasis scales. Some available preparations include Salex (salicylic acid), AmLactin (lactic acid), or Lac-Hydrin (lactic acid) lotions. These may be used one to three times a day on the body and do not generally have a risk of problematic skin thinning (atrophy). Overuse or use on broken, inflamed skin may cause stinging, burning, and more irritation. These stronger preparations should not be used over delicate skin like eyelids, face, or genitals. Other bland moisturizers including Vaseline and Crisco vegetable shortening may also be helpful in at least reducing the dry appearance of psoriasis.



• Immunomodulators (tacrolimus and pimecrolimus) have also been used with some success in limited types of psoriasis. These have the advantage of not causing skin thinning. They may have other potential side effects, including skin infections and possible malignancies (cancers). The exact association of these immunomodulator creams and cancer is controversial.



• Bath salts or bathing in high-salt-concentration waters like the Dead Sea in the Middle East may help some psoriasis patients. Epsom salt soaks (available over the counter) may also be helpful for a number of patients. Overall, these are quite safe with very few possible side effects.



• Coal tar is available in multiple preparations, including shampoos, bath solutions, and creams. Coal tar may help reduce the appearance and decrease the flakes in psoriasis. The odor, staining, and overall messiness with coal tar may make it harder to use and less desirable than other therapies. A major advantage with tar is lack of skin thinning.



• Anthralin is available for topical use as a cream, ointment, or paste. The stinging, possible irritation, and skin discoloration may make this less acceptable to use. Anthralin may be applied for 10-30 minutes to psoriatic skin.
• What injections or infusions are available for psoriasis?

The newest category of psoriasis drugs are called biologics. All biologics modulate (adjust) and sometime suppress (quiet) the immune system that is overactive in psoriasis. Currently available biologic drugs include alefacept (Amevive), adalimumab (Humira), infliximab (Remicade), etanercept (Enbrel), and ustekinumab (Stelara). Newer drugs are in development and may be on the market in the near future. As this class of drugs is fairly new, ongoing monitoring and adverse effect reporting continues and long-term safety continues to be monitored. Although previously available, efalizumab (Raptiva) was removed from the U.S. market in early 2009 due to reported safety concerns for the development of a serious brain disease, progressive multifocal leukoencephalopathy (PML). Individuals still taking Raptiva should contact their health-care professional to discuss risks and benefits of treatment with this drug.
A recently approved biologic product for adults who have a moderate to severe form of psoriasis is ustekinumab (Stelara). Stelara is a laboratory-produced antibody that treats psoriasis by blocking the action of two proteins (interleukins) that contribute to the overproduction of skin cells and inflammation.
Some biologics are self-injections for home use while others are intramuscular injections or intravenous infusions in the physician's office.
Biologics have some screening requirements such as a tuberculosis screening test (TB skin test or PPD test) and other labs prior to starting therapy.
As with any drug, side effects are possible with all biologic drugs. Common potential side effects include mild local injection-site reactions (redness and tenderness). There is concern of serious infections and potential malignancy with nearly all biologic drugs.
Precautions include patients with known or suspected hepatitis B or C infection, active tuberculosis, and possibly HIV/AIDS. As a general consideration, these drugs may not be an ideal choice for patients with a history of cancer and patients actively undergoing cancer therapy.
In particular, there may be an increased association of lymphoma in patients taking biologics. It is not at all certain if this association is directly caused by these drugs. In part, this is because it is known that certain diseases like rheumatoid arthritis or psoriasis may be associated with an inherent increase in the overall risk of some infections and malignancies.
Biologics are expensive medications ranging in price from several to tens of thousands of dollars per year per person. Their use may be limited by availability, cost, and insurance approval. Not all insurance drug plans may fully cover these drugs for all conditions. Patients need to check with their insurance and may require a prior authorization request for coverage approval. Some of the biologics manufacturers have patient-assistance programs to help with financial issues.
The choice of the right medication for your condition depends on many medical factors. Additionally, convenience of receiving the medication and lifestyle may be factors in choosing the right biologic medication.
Currently, the four main classes of biologic drugs for psoriasis are:

1. TNF (tumor necrosis factor) blockers,
2. drugs that block T-cell activation and the movement of T-cells,
3. drugs that decrease the number of activated T-cells, and
4. drugs that interfere with interleukin chemical messengers of inflammation.

TNF blockers
TNF blockers include Enbrel (etanercept), Remicade (infliximab) and Humira (adalimumab). TNF-alpha blocking drugs may have an advantage of treating psoriatic arthritis and psoriasis skin disease. Their disadvantage is that some patients may notice a decrease in the effectiveness of TNF-alpha blocking drugs over months to years.
TNF blockers are generally not used in patients with demyelinating (neurological) diseases like multiple sclerosis, congestive heart failure, or patients with severe overall low blood counts called pancytopenia.
The major side effect of these class of drugs is suppression of the immune system. Because of the increased risk of infections while on these drugs, patients should promptly report fevers or signs of infection to their physicians. Minor side effects have included autoimmune conditions like lupus or flares in lupus. Additionally, it is best to avoid any live vaccines while using TNF blockers.

• Enbrel (etanercept) is a self-injectable medication for home use. It is injected via a small needle just under the skin, called subcutaneous injection. It is usually dosed once or twice week by patients at home after training with their physician or the nursing staff. Sometimes a higher loading dose is used for the first 12 weeks and then it is "stepped down" to half the dose after the first 12 weeks. Enbrel has the advantage of at least 16 years of clinical use and long-term experience.
• Remicade (infliximab) is an intravenous (IV) medication strictly for physician office or special infusion medical center use. It is dosed specifically based on your weight. It is currently not for home use or self-injection. It is injected slowly over time via a small needle into a vein. It may usually be dosed once a week. There have been reports of antibodies to this drug in patients taking it for some time. These antibodies may cause a greater drug-dose requirement for achieving disease improvement or failure to improve. The IV route may be more time-consuming, requiring physician during the infusions. Remicade has the advantage of fast disease response and good potency.
• Humira (adalimumab) is a self-injectable medication for home use. It is injected via a small needle just under the skin as a subcutaneous dose. It is usually dosed once every other week, totaling 26 injections in one year. Dosing is individualized and should be discussed with your physician. Sometimes a higher loading dose is used for the first dose (80 mg) and then it is continued at 40 mg every other week. It may give results as soon as one to two weeks of therapy. Humira has the advantage of at least 11 years of clinical use and long-term experience.

Drugs that decrease the number of activated T-cells

• Amevive (alefacept) decreases the number of available activated T-cells that play a role in causing psoriasis. It is given intramuscularly (injected in the muscle) usually in the physician's office and given once a week for 12 weeks. Many patients may see improvement in their symptoms that lasts approximately 12 months (more or less). Amevive may not be uniformly effective for all patients, and some patients improve more than others. The average time to maximum improvement for many patients is about 14 weeks.
  
  Amevive should generally not be used in patients with HIV infections as the drug causes a decrease in the CD4 cells (part of the immune system that HIV also attacks).
  
  Also, because of the immune-system suppression, Amevive may not be a good choice in patients with active cancer or infection. As Amevive is one of the two currently available drugs that inhibits T cells directly, there may be a potential concern for immunosuppression and increased susceptibility to infections including PML. The risks and benefits of treatment with biologics need to be assessed for each individual.

Drugs that interfere with interleukin mechanisms

• Ustekinumab is the newest biologic injectable medication used to modulate the immune system. It is an interleukin-12/23 human monoclonal antibody. Ustekinumab targets chemical messengers in the immune system involved in skin inflammation and skin-cell production. This drug is dosed subcutaneously (just under the skin) once a quarter (every three months). It has been very promising with very good clearance rates in the clinical trials. A major advantage may be the convenience of a quarterly medication. The concerns for infection and malignancy may be similar to the other biologics.