Management Psoriasis

1 management

1.1 topical agents
1.2 light exposure
1.3 systemic agents
1.4 surgery
1.5 diet

management

schematic of psoriasis treatment ladder

while no cure available psoriasis, many treatment options exist. topical agents typically used mild disease, phototherapy moderate disease, , systemic agents severe disease.

topical agents

topical corticosteroid preparations effective agents when used continuously 8 weeks; retinoids , coal tar found of limited benefit , may no better placebo. greater benefit has been observed potent corticosteroids when compared potent corticosteroids. vitamin d analogues such paricalcitol found superior placebo. combination therapy vitamin d , corticosteroid superior either treatment alone , vitamin d found superior coal tar chronic plaque psoriasis.

moisturizers , emollients such mineral oil, petroleum jelly, calcipotriol, , decubal (an oil-in-water emollient) found increase clearance of psoriatic plaques. emollients have been shown more effective @ clearing psoriatic plaques when combined phototherapy. however, emollients have no impact on psoriasis plaque clearance or may decrease clearance achieved phototherapy. emollient salicylic acid structurally similar para-aminobenzoic acid (paba), commonly found in sunscreen, , known interfere phototherapy in psoriasis. coconut oil, when used emollient in psoriasis, has been found decrease plaque clearance phototherapy. medicated creams , ointments applied directly psoriatic plaques can reduce inflammation, remove built-up scale, reduce skin turnover, , clear affected skin of plaques. ointment , creams containing coal tar, dithranol, corticosteroids (i.e. desoximetasone), fluocinonide, vitamin d3 analogs (for example, calcipotriol), , retinoids routinely used. use of finger tip unit may helpful in guiding how topical treatment use.

vitamin d analogues may useful steroids; however, alone have higher rate of side effects. may allow less steroids used.

another topical therapy used treat psoriasis form of balneotherapy, involves daily baths in dead sea. done 4 weeks benefit attributed sun exposure , uvb light. cost-effective , has been propagated effective way treat psoriasis without medication. decreases of pasi scores greater 75% , remission several months have commonly been observed. side-effects may mild such itchiness, folliculitis, sunburn, poikiloderma, , theoretical risk of nonmelanoma skin cancer or melanoma has been suggested. however, more recent studies have determined there not appear increased risk of melanoma in long-term. data inconclusive respect nonmelanoma skin cancer risk, support idea therapy associated increased risk of benign forms of sun-induced skin damage such as, not limited to, actinic elastosis or liver spots. dead sea balneotherapy effective psoriatic arthritis.

light exposure

phototherapy in form of sunlight has long been used psoriasis. wavelengths of 311–313 nanometers effective, , special lamps have been developed application. exposure time should controlled avoid on exposure , burning of skin. uvb lamps should have timer turn off lamp when time ends. amount of light used determined person s skin type. increased rates of cancer treatment appear small. narrow band uvb light (nbuvb) phototherapy has been demonstrated have similar efficacy puva.

one of problems clinical phototherapy difficulty many patients have gaining access facility. indoor tanning resources ubiquitous today , considered means patients uv exposure when dermatologist provided phototherapy not available. indoor tanning used many people treatment psoriasis; 1 indoor facility reported 50% of clients using center psoriasis treatment; reported 36% doing same thing. however, concern use of commercial tanning tanning beds emit uva might not treat psoriasis. 1 study found plaque psoriasis responsive erythemogenic doses of either uva or uvb, exposure either can cause dissipation of psoriatic plaques. require more energy reach erythemogenic dosing uva.

uv light therapies have risks; tanning beds no exception, particularly in link between uv light , increased chance of skin cancer. there increased risks of melanoma, squamous cell , basal cell carcinomas; younger psoriasis patients, particularly under age 35, @ increased risk melanoma uv light treatment. world health organization (who) listed tanning beds carcinogens. review of studies recommends people susceptible skin cancers exercise caution when using uv light therapy treatment.

a major mechanism of nbuvb induction of dna damage in form of pyrimidine dimers. type of phototherapy useful in treatment of psoriasis because formation of these dimers interferes cell cycle , stops it. interruption of cell cycle induced nbuvb opposes characteristic rapid division of skin cells seen in psoriasis. activity of many types of immune cells found in skin suppressed nbuvb phototherapy treatments. common short-term side effect of form of phototherapy redness of skin; less common side effects of nbuvb phototherapy itching , blistering of treated skin, irritation of eyes in form of conjunctival inflammation or inflammation of cornea, or cold sores due reactivation of herpes simplex virus in skin surrounding lips. eye protection given during phototherapy treatments.

psoralen , ultraviolet phototherapy (puva) combines oral or topical administration of psoralen exposure ultraviolet (uva) light. mechanism of action of puva unknown, involves activation of psoralen uva light, inhibits abnormally rapid production of cells in psoriatic skin. there multiple mechanisms of action associated puva, including effects on skin s immune system. puva associated nausea, headache, fatigue, burning, , itching. long-term treatment associated squamous cell carcinoma (but not melanoma). combination therapy moderate severe psoriasis using puva plus acitretin resulted in benefit, acitretin use has been associated birth defects , liver damage.

systemic agents

pictures of patient psoriasis (and psoriatic arthritis) @ baseline , 8 weeks after initiation of infliximab therapy.

psoriasis resistant topical treatment , phototherapy may treated systemic therapies including medications mouth or injectable treatments. people undergoing systemic treatment must have regular blood , liver function tests check medication toxicities. pregnancy must avoided of these treatments. majority of people experience recurrence of psoriasis after systemic treatment discontinued.

non-biologic systemic treatments used psoriasis include methotrexate, ciclosporin, hydroxycarbamide, fumarates such dimethyl fumarate, , retinoids. methotrexate , ciclosporin drugs suppress immune system; retinoids synthetic forms of vitamin a. these agents regarded first-line treatments psoriatic erythroderma. oral corticosteroids should not used, can severely flare psoriasis upon discontinuation.

biologics manufactured proteins interrupt immune process involved in psoriasis. unlike generalised immunosuppressive drug therapies such methotrexate, biologics target specific aspects of immune system contributing psoriasis. these medications well-tolerated , limited long-term outcome data have demonstrated biologics safe long-term use in moderate severe plaque psoriasis. however, due immunosuppressive actions, biologics have been associated small increase in risk infection.

guidelines regard biologics third-line treatment plaque psoriasis following inadequate response topical treatment, phototherapy, , non-biologic systemic treatments. safety of biologics during pregnancy has not been assessed. european guidelines recommend avoiding biologics if pregnancy planned; anti-tnf therapies such infliximab not recommended use in chronic carriers of hepatitis b virus or individuals infected hiv.

several monoclonal antibodies target cytokines, molecules cells use send inflammatory signals each other. tnf-α 1 of main executor inflammatory cytokines. 4 monoclonal antibodies (mabs) (infliximab, adalimumab, golimumab, , certolizumab pegol) , 1 recombinant tnf-α decoy receptor, etanercept, have been developed inhibit tnf-α signaling. additional monoclonal antibodies, such ixekizumab, have been developed against pro-inflammatory cytokines , inhibit inflammatory pathway @ different point anti-tnf-α antibodies. il-12 , il-23 share common domain, p40, target of fda-approved ustekinumab. in 2017 fda approved guselkumab plaque psoriasis.

two drugs target t cells efalizumab , alefacept. efalizumab monoclonal antibody targets cd11a subunit of lfa-1. blocks adhesion molecules on endothelial cells line blood vessels, attract t cells. efalizumab voluntarily withdrawn european market in february 2009 , market in june 2009 manufacturer due medication s association cases of progressive multifocal leukoencephalopathy. alefacept blocks molecules dendritic cells use communicate t cells , causes natural killer cells kill t cells way of controlling inflammation. apremilast may used.

individuals psoriasis may develop neutralizing antibodies against monoclonal antibodies. neutralization occurs when antidrug antibody prevents monoclonal antibody such infliximab binding antigen in laboratory test. specifically, neutralization occurs when antidrug antibody binds infliximab s antigen binding site instead of tnf-α. when infliximab no longer binds tumor necrosis factor alpha, no longer decreases inflammation, , psoriasis may worsen. neutralizing antibodies have not been reported against etanercept, biologic drug fusion protein composed of 2 tnf-α receptors. lack of neutralizing antibodies against etanercept secondary innate presence of tnf-α receptor, , development of immune tolerance.

surgery

limited evidence suggests removal of tonsils may benefit people chronic plaque psoriasis, guttate psoriasis, , palmoplantar pustulosis.

diet

uncontrolled studies have suggested individuals psoriasis or psoriatic arthritis may benefit diet supplemented fish oil rich in eicosapentaenoic acid (epa) , docosahexaenoic acid (dha). diet recommendations include consumption of cold water fish (preferably wild fish, not farmed) such salmon, herring, , mackerel; virgin olive oil; legumes; vegetables; fruits; , whole grains; , avoid consumption of alcohol, red meat, , dairy products. effect of consumption of caffeine (including coffee, black tea, mate, , dark chocolate) remains determined.

there higher rate of celiac disease among people psoriasis. when adopting gluten-free diet, disease severity decreases in people celiac disease , anti-gliadin antibodies.