Medical Treatment

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Treatment

The majority of medical treatment for psoriasis is dependent upon locally applied topical creams. Which include:
Emollients and Salicylic Acid
Aqueous cream emollients or greasier ones such as 50% white soft paraffin in liquid paraffin may help to reduce
scaling. These can be applied whenever the skin feels dry. Preparations containing salicylic acid can be used on
very scaly patches (known as plaques).
Topical Steroids
In certain situations these steroid preparations may be indicated. On trunk and limb psoriasis they tend to be
largely ineffective. They are used when psoriasis affects the face, hairline, ears, umbilicus (tummy button), or
groin. They are also used when there is psoriasis present on the scalp. Potent (strong) steroids are required to
control psoriasis in these areas. If ongoing treatment is required on a non hair bearing area then close supervision
is required and an ongoing potent treatment should not be encouraged because of serious future side effects.
Once psoriasis has cleared locally it is often possible to control the psoriasis in these areas with a milder
preparation which is safer for long-term usage.
Coal Tar Preparations
There are purified tar preparations which can help to reduce the inflammation and irritation of psoriasis, as well as
being effective at clearing the disease. In practice these take at least 6 to 8 weeks to achieve any real response.
The purified tars are clean to use and do not stain clothing. Messier tar preparations are sometimes used but
usually only in severer psoriasis. Recent court cases in the US have resulted in coal tar preparations being
labelled with cancer warnings. Continued long-term use of coal tar preparations due to their carcinogenity is not
recommended.
Dithranol
Dithranol is a helpful treatment for resistant psoriasis as it slows up cell turnover in the surface of the skin. When
used at home the most cosmetically acceptable way of using the product is the short contact Dithranol method. If
Dithranol is left in contact with normal skin it can cause burning, staining and damage any clothing worn.
Short contact Dithranol involves applying a Dithranol cream to the affected areas of psoriasis with gentle rubbing
in until it is absorbed. Although usually recommended to be left on for 30 to 60 minutes, in practice the majority of
individuals find that it works as well when left on for 10 minutes. This then is usually a more acceptable way of
using the product as an individual will either have to stand naked with the cream on for 10 minutes or wear an old
dressing gown which may then become stained. If used for a 10 minute regime then small amounts of Dithranol
landing on normal skin should not cause any problems provided this is washed off thoroughly. After 10 minutes the
preparation is washed off with copious amounts of soap and water in the shower or bath, the skin dried with an old
towel and then a moisturizing cream applied to prevent any drying out from all the soap that has been used.
As the psoriasis starts to clear the treated areas will gradually stain brown, particularly on the skin around. This
staining will disappear once the Dithranol is discontinued. The Dithranol has to be repeated on a daily basis and
after the first week the strength can be increased. The strength of the Dithranol is usually increased at weekly
intervals to the maximum that an individual is able to tolerate without burning. Dithranol treatment is mainly used
for psoriasis on the trunk and limbs.
If Dithranol is effective it can be used on any subsequent outbreaks of psoriasis but should always be started at a
weak level. If burning of the skin results then discontinuation of treatment may be necessary or reduction to a
weaker strength may be required.
Vitamin D Analogues (Calcipotriol and Tacalcitol Preparations)
Preparations related to vitamin D, known as vitamin D analogues have been introduced for the treatment of
psoriasis. They can be helpful in some individuals and are cosmetically highly acceptable. They appear to be
relatively safe, although at the present time their safety in pregnancy and in breast feeding is not clearly
established. It can take typically 4 or 6 weeks to know whether these preparations are effective. They are usually
of benefit in reducing scaling but may not actually clear psoriasis completely when compared to Dithranol therapy.
Irritation can occur if the vitamin D analogue is applied onto facial skin or genital skin.
Vitamin A Analogues (Tazarotene)
Tazarotene is new vitamin A gel applied once daily to patches of psoriasis. Some irritation may occur with its usage
but otherwise it appears to be a cosmetically acceptable product effective in some individuals.
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Scalp
Regular shampooing is required to control psoriasis in this area. If regular shampooing (daily) does not control it
then a steroid scalp application or vitamin D analogue scalp lotion can be used. These appear to be safe for
usage in the scalp even in the long term. If there are thick areas of scaling in the scalp preparations containing
salicylic acid (Ung Cocois Co, Ung Pyragallol Co) may have to be used. These are messy preparations which are
usually required to be left on overnight under a shower cap and washed off with a strong medicated shampoo in
the morning. There are a number of new shampoos containing salicylic acid which when used twice a week in
addition to regular daily shampooing with ordinary shampoos can help to reduce the subsequent rebuilding up of
the scalp. Nails
There is no effective treatment for nail psoriasis.

Ultraviolet Light Treatment
Sunlight is an effective treatment for psoriasis. Phototherapy (artificial ultraviolet light) may be indicated for
resistant psoriasis (see moderate and severe psoriasis).
Outcome
In the majority of individuals it is possible to treat psoriasis reasonably effectively but not cure the problem. 1 out of
5 individuals may not see any recurrence within a 5 year period. 4 out of 5 individuals however will experience a
recurrence of their psoriasis..."

Methotrexate

Methotrexate is
very effective for
psoriasis.
Unfortunately, it
may be
associated with
severe acute and
chronic adverse
reactions
including acute
hematologic
toxicity and acute
and chronic
hepatotoxicity.
This therapy
should be limited
to patients with
refractory,
disabling
psoriasis.[42] The
goal of
methotrexate
therapy in
psoriasis is to
control the
eruption not to
completely
eliminate it.
Careful dosing
and monitoring is
essential.
Baseline
laboratory tests
should include
complete blood
count and
differential and
liver function
tests. Most often,
a test dose of 2.5
to 5.0 mg is given
followed by
laboratory testing
in 5-7 days.
Monitoring is
repeated weekly
during the period
of dosage
increases to a
maximum of 15-25
mg/week.
Because
methotrexate is
cleared by renal
excretion, caution
must be exercised
in patients with
suspected renal
impairment,
especially the
elderly. Before
utilizing
methotrexate, the
dermatologist
should be
completely familiar
with
recommendations
from the 1998
consensus
conferance which
details
recommendations
for pretreatment
evaluation and
laboratory and
liver biopsy
monitoring.[42] In
addition, a
description of
leukovorin (folinic
acid) rescue for
methotrexate
overdosage is
given as well as a
detailed listing of
drugs that interact
with methotrexate
to increase toxicity
and the
mechanism of the
interactions.
Though this is
frequently
neglected, the
physician should
document the
reasons (history,
physical exam) for
choosing
methotrexate and
the risk/benefit
counselling the
patient
received.[44]

Causes
Psoriasis may be one of the oldest recorded skin conditions. It was probably first described around 35 AD. Some
evidence indicates an even earlier date. Yet, until recently, little was known about psoriasis.
While scientists still do not fully know what causes psoriasis, research has significantly advanced our
understanding. One important breakthrough began with the discovery that kidney-transplant recipients who had
psoriasis experienced clearing when taking cyclosporine. Since cyclosporine is a potent immunosuppressive
medication, this indicates that the immune system is involved. Immune Mediated. Researchers now believe that
psoriasis is an immune-mediated condition. This means the condition is caused by faulty signals in the body’s
immune system. It is believed that psoriasis develops when the immune system tells the body to over-react and
accelerate the growth of skin cells. Normally, skin cells mature and are shed from the skin’s surface every 28 to 30
days. When psoriasis develops, the skin cells mature in 3 to 6 days and move to the skin surface. Instead of being
shed, the skin cells pile up, causing the visible lesions. Genes. Researchers have identified genes that cause
psoriasis. These genes determine how a person’s immune system reacts. These genes can cause psoriasis or
another immune-mediated condition, such as rheumatoid arthritis or type 1 diabetes. The risk of developing
psoriasis or another immune-mediated condition, especially diabetes or Crohn’s disease, increases when a close
blood relative has psoriasis. Family History. Some people who have a family history of psoriasis never develop this
condition. Research indicates that a “trigger” is needed. Stress, skin injuries, a strep infection, certain medications,
and sunburn are some of the known potential triggers. Medications that can trigger psoriasis are anti-malarial
drugs, beta-blockers (medication used to treat high blood pressure and heart conditions), and lithium.
Dermatologists have seen psoriasis suddenly appear after a person takes one of these medications, gets a strep
infection, or experiences another trigger. Psoriasis research continues to accelerate at a rapid pace and will
continue to advance our knowledge of what causes psoriasis. Quality of Life All types of psoriasis, ranging from
mild to severe, can affect a person’s quality of life. Living with this lifelong condition can be physically and
emotionally challenging. Itching, soreness, and cracked and bleeding skin are common. Nail psoriasis can be
painful. Even the simple act of squeezing a tube of toothpaste can hurt. One woman described her psoriasis as
feeling like “a bad sunburn that won’t go away.” Several studies have shown that people often feel frustrated. In
some cases, psoriasis limits activities and makes it difficult to perform job responsibilities. The National Psoriasis
Foundation reports that 56 million work hours are lost each year by those who have psoriasis. Additionally, a
survey conducted by the National Psoriasis Foundation in 2002 indicates that 26% of people living with moderate to
severe psoriasis have been forced to change or discontinue their normal daily activities.
Studies also have shown that stress, anxiety, loneliness, and low self-esteem are part of daily life for people living
with psoriasis. One study found that thoughts of suicide are three times higher for psoriatics than the general
population. Embarrassment is another common feeling. Imagine getting your hair cut and noticing that the stylist or
barber is visibly uncomfortable. What if you extended your hand to someone and the person recoiled? How would
you feel if you spent most of your life trying to hide your skin?

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