Psoriasis varies widely in its clinical expression, from a
single fingernail pit to widespread disfiguring skin lesions
and disabling arthritis. The primary goal of therapy
is to maintain control of the illness so as to avoid
disruption of the patient’s quality of life, as cure is seldom
achieved. Treatment options include topical therapies, phototherapies , systemic therapies , and others therapies. Besides that , we still have historical treatment which is received brief popularity at particular time periods or within certain geographical regions.
In order to effectively cure psoriasis after treatment , there are some follow-up care that we need to do also.
Topical treatment
Topical psoriasis treatment includes corticosteroids, calcipotriol/calcipotriene, tazarotene, and anthralin.
Topical Corticosteroids (Diprosone®, Valisone®):
Topical steroids are the most commonly prescribed psoriasis medications and they are available as creams, ointments, gels, lotions, solutions, oils, and shampoos. They can be used anywhere on the body and work quite quickly, often within 1-2 weeks.However, with long term use, steroids often lose their effectiveness.
Usually you won't have any side effects with short term use. However, longer use particularly with stronger preparations, may cause thinning of the skin, stretch marks, dilated blood vessels, rosacea, perioral dermatitis, bruising, and hair growth. Progression to a more active form of psoriasis for example, pustular or erythrodermic psoriasis, increased susceptibility to infections, and a flare up of the psoriasis when the medication is stopped.
Topical corticosteroids can be absorbed into the blood circulation and cause a number of side effects in your body, particularly if you are treating large areas and/or using strong steroids. Only mild steroids should be used on the more sensitive skin, such as your face, and in skin folds. Stronger steroids are usually required elsewhere. Pulsed betamethasone diproprionate used three times, 12 hours apart is shown to be useful in maintaining psoriasis. This regimen is suitable for weekend use while non-cortisone can be used during the weekdays.
Topical Calcipotriol/Calcipotriene (Dovonex®)
Calcipotriol/calcipotriene is a derivative of vitamin D, and it is available in a cream, ointment, and scalp solution. The mechanism of action is unknown, but it is known to slow the excessive turnover of epidermal cells, by influencing keratinocyte differentiation.
The improvement usually starts within 2-3 weeks. The full effect may require up to 2 months. This is effective in a large number of psoriatic with mild to moderate disease. The full effect may require up to 2 months. It is usually effective and safe for long term use. Calcipotriol is an effective treatment in a large number of psoriatic patients with mild to moderate disease. There is a risk of hypercalcaemia if calcipotriol is used extensive,y, "ut at dosages of less than 100 gm per week calcium metabolism is not affected. Since it may cause irritatio., calci0otriol is not usually used on t(e face, genitals, or in skin foldc.
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T(is cal be used in combination with other topical agents as well as photo therapy, (PUVA or UVB) and systemic therapies such as cyclosporine A or acitretin. The use of calcipotriol in combination with other treatments (i.e. topical steroids, cyclosporin, acitretin, PUVA phototherapy or UVB phototherapy) improves efficacy allowing for dosage reduction of the other treatments. However, since the stability of calcipotriol in its marketed formulations may be affected by other compounds, mixtures of calcipotriol and other topical agents should not be prepared.
Topical Tazarotene (Tazorac®):
Tazarotene is a selective retinoid with properties that are similar to vitamin A. Tazarotene is available as a cream and gel. It is effective in the treatment of psoriasis, acne, and photoaging. In the treatment of psoriasis, it may be used by itself, or in combination with a corticosteroid cream or ointment, calcipotriol/calcipotriene or light treatment (UVB, PUVA).
Irritation is common with tazarotene, but you can minimize this by applying a thin layer of the medication only to the patches and avoiding the uninvolved surrounding skin and/or protecting the surrounding skin with petrolatum. You should not use tazarotene on the genitals or in the skin folds. You should not use this medication if you are pregnant.
The mechanism of action is unknown. It may induce growth suppressor genes in keratinocytes. The efficacy is usually slow and starts with reduction of plaque thickness and some improvement in redness and scaling usually occurs after 3 months.
Side effects include redness and burning. It should not be used in women who wish to become pregnant. Application is usually used daily.
Anthralin (Dithranol®):
This is derived from chrysarobin, from the bark of the Araroba tree. Anthralin is available as a cream, ointment, and scalp lotion. Lower concentrations can be left on overnight, while stronger ones (1% or higher) should be left on for 15-30 minutes. It is used to treat plaque and guttate psoriasis. Short contact with a high concentration works better than longer contact with a low concentration.
Anthralin slows down the growth of the skin cells and has anti-inflammatory actions. Anthralin can cause staining (purple/brown color) of your clothes, skin, and hair, which limits its use, irritation may also occur, but this can be minimized by applying the anthralin only to the psoriasis patches and avoiding uninvolved skin. You should not use anthralin on the face, genitals, or in the skin folds.
In hospital, administration of anthralin often will clear psoriasis within 2 weeks. Short contact anthralin is effective in a large number of individuals with mild to moderate psoriasis.
In hospital and Day Care Ingram regime involves anthralin paste, coal tar baths as well as ultraviolet light. Short contact anthralin can be administered at home and is good for localized areas of psoriasis. It may be used in combination with both UVB and PUVA.
A product developed in Sweden called Micanol® is designed for short contact use. The anthralin does not stain if it is washed off with cool water.
The mechanism of action is unknown. They may effect expression of genes for cytokines and cell adhesion molecules.
- Dithrocreme® 0.1%, 0.25%, 0.5%
- DithrocremeHP® 1%
- Dithroscalp® 0,25% 0,5%
- Micanol® 1%
Phototherapies
There are two types of phototherapies
Phototherapy
It has long been recognized that daily, short, non-burning exposure to sunlight helped to clear or improve psoriasis. Niels Finsen was the first physician to investigate the therapeutic effects of sunlight scientifically and to use sunlight in clinical practice. This became known as phototherapy.
Sunlight contains many different wavelengths of light. It was during the early part of the 20th century that it was recognised that for psoriasis the therapeutic property of sunlight was due to the wavelengths classified as ultraviolet (UV) light.
Ultraviolet wavelengths are subdivided into UVA (380–315 nm) UVB (315–280 nm), and UVC (< 280 nm). Ultraviolet B (UVB) (315–280 nm) is absorbed by the epidermis and has a beneficial effect on psoriasis. Narrowband UVB (311 to 312 nm), is that part of the UVB spectrum that is most helpful for psoriasis. Exposure to UVB several times per week, over several weeks can help people attain a remission from psoriasis.
Ultraviolet light treatment is frequently combined with topical (coal tar, calcipotriol) or systemic treatment (retinoids) as there is a synergy in their combination. The Ingram regime, involves UVB and the application of anthralin paste. The Goeckerman regime combines coal tar ointment with UVB.
Figure 1: before and after patient received UVB treatment
Photochemotherapy
Psoralen and ultraviolet A phototherapy (PUVA) combines the oral or topical administration of psoralen with exposure to ultraviolet A (UVA) light. Precisely how PUVA works is not known. The mechanism of action probably involves activation of psoralen by UVA light which inhibits the abnormally rapid production of the cells in psoriatic skin. There are multiple mechanisms of action associated with PUVA, including effects on the skin immune system.
PUVA is associated with nausea, headache, fatigue, burning, and itching. Long-term treatment is associated with squamous-cell and melanoma skin cancers.
Figure 2: before and after patient received UVA treatment
Systemic Treatment
Psoriasis which is resistant to topical treatment and phototherapy is treated by medications that are taken internally by pill or injection. This is called systemic treatment. Patients undergoing systemic treatment are required to have regular blood and liver function tests because of the toxicity of the medication. Pregnancy must be avoided for the majority of these treatments. Most people experience a recurrence of psoriasis after systemic treatment is discontinued.
The three main traditional systemic treatments are methotrexate, cyclosporine and retinoids. Methotrexate and cyclosporine are immunosupressant drugs; retinoids are synthetic forms of vitamin A. Other additional drugs, not specifically licensed for psoriasis, have been found to be effective. These include the antimetabolite tioguanine, the cytotoxic agent hydroxyurea, sulfasalazine, the immunosupressants mycophenolate mofetil, azathioprine and oral tacrolimus. These have all been used effectively to treat psoriasis when other treatments have failed. Although not licensed in many other countries fumaric acid esters have also been used to treat severe psoriasis in Germany for over 20 years.
Biologics are manufactured proteins that interrupt the immune process involved in psoriasis. Unlike generalised immunosuppressant therapies such as methotrexate, biologics focus on specific aspects of the immune function leading to psoriasis. These drugs (interleukin antagonists) are relatively new, and their long-term impact on immune function is unknown. They are very expensive and only suitable for very few patients with psoriasis. Ustekinumab (IL-12 and IL-23 blocker) shows hopeful results for psoriasis therapy.
A new natural systemic option, XP-828L, for mild to moderate psoriasis relief has been developed by a Canadian life science and technology company. This oral product with clinically proven efficacy and safety is extracted through a patented process from whey and has immuno-modulatory effects.
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