Treatment of Psoriasis

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Psoriasis is a chronic disease and, although there are treatments for its symptomatology, none of them is curative and, therefore, when left the psoriasis lesions can reappear. There are multiple treatments (topical and systemic) and it may happen that the treatment that works in one person is not effective in another.

Non-pharmacological treatment

The following habits are considered harmful for psoriasis and you have to try to reduce or eliminate them:

Woman seated in Yoga position

Emotional tension. A high level of emotional tension can be the trigger of the disease and subsequent psoriatic outbreaks. Exercise or meditation can help control this emotional state and decrease outbreaks.

Person running and an upward arrow indicating an increase in exercise.

Weight. Overweight people tend to have a worse response to the treatment of psoriasis and it is common that they also present psoriasis to the sheets. Therefore, it is advisable to avoid sedentary lifestyle and make a healthy life to maintain the right weight for each person.

Cigarette crossed out on a "no smoking" poster

Tobacco. It can be a trigger of the disease. Long-term smoking in large quantities is considered a risk for the development of psoriasis. In all patients with psoriasis advised to stop smoking as an improvement measure.

Two beer mugs crossed out indicating that alcohol is forbidden.

Alcohol. Alcohol can increase the risk of having psoriasis so it is advised to avoid its intake.

Tube and hand with moisturiser

Dry skin. The daily use of non-drying hygienic products and moisturizers help to balance the loss of water from the skin and reduce the impact of outbreaks, improving the predisposition of the skin to topical treatments.

Correct pills

Medications contraindicated. The taking of some medicines that contain lithium salts, beta-blockers, NSAIDs or calcium antagonists can trigger outbreaks or aggravate the state of the disease.

Sun

Environmental factors. Dry environments, excessive heating or air conditioning can aggravate the effects of psoriasis. It is advisable to avoid exposure for a long time. It has also been shown that exposure to ultraviolet light rays (sunlight) is beneficial to improve outbreaks of the disease. Performing sun baths avoiding maximum exposure hours helps to improve the state of the lesions caused by outbreaks.

Pharmacological treatment

Topical preparations

Topical treatments. These are the treatment of choice for localised forms and small‑scale psoriasis. These treatments have the fewest side effects, but are inconvenient and must be applied continuously. There are various types of topical treatments. The most widely used and effective are topical corticosteroids, which come in various forms and doses. The most suitable should be selected according to the characteristics of the lesions, their extent and the area to be treated. To prevent cutaneous atrophy and the possible appearance of stretch marks, these must not be used continuously. You can also use vitamin D analogues, topical retinoids, coal tar derivatives, topical immunomodulators, emollients (moisturisers), and keratolytic substances (which help to peel). They can be combined, rotated or used in sequence, in order to enhance the effectiveness of each treatment and avoid the side effects associated with continuous application.

Patient receiving photodynamic therapy

Phototherapy. Exposure to ultraviolet (UV) rays from sunlight or artificial light slows down the elimination of dead skin cells and reduces flaking and inflammation. Treatment with narrow‑band ultraviolet B (UVB‑BE) radiation, and ultraviolet A (UVA) in combination with psoralenes (an oral UVA radiation enhancer) (PUVA) are effective treatments for extensive forms of psoriasis or forms that affect certain locations (the palms and/or soles of feet) that do not respond adequately to topical treatments. Phototherapy can be difficult to perform on some patients due to their availability (about 3 sessions per week are usually needed), as well as the possible long‑term side effects (increased photoageing and a greater risk of skin cancer).

Medicines, pills

Systemic treatment. Systemic treatments are indicated in cases of extensive or serious psoriasis. The drugs are usually effective, but they are not free from important side effects, making frequent controls necessary (analytical and clinical). Cyclosporine is a very effective, fast‑acting drug, but can cause outbreaks of psoriasis when the treatment is stopped, meaning the dose has to be reduced gradually. It requires the blood pressure and kidney function to be controlled. Because of the potential risk of renal effects, it is recommended that this drug be used in short cycles of 3‑4 months. Methotrexate is a drug that takes a little longer to work than cyclosporine, but usually manages to control psoriasis for long periods of time. It requires the liver function to be controlled and it is not advisable to exceed the maximum total dose due to the risk of liver damage in the long term. Acitretin is a less‑effective drug, but it can be very useful in a subgroup of patients, especially in combination with phototherapy. It requires triglyceride and cholesterol levels to be controlled and usually causes increased dryness of the skin and mucous membranes (lips). This drug can cause foetal malformations in pregnant women, even up to 2 years post‑treatment, so it is not recommended for use in women of childbearing age.

New therapies

Injection

Biological treatments. Biological treatments (etanercept, infliximab, adalimumab, ustekinumab, secukinumab, and ixekizumab) are recent drugs. Biological treatments are indicated in severe forms of psoriasis. According to the European consensus, these are second‑line drugs and should only be prescribed for patients who have not responded to at least two classic systemic treatments (phototherapy, methotrexate, cyclosporine, or acitretin), or where these could not be prescribed because of some contraindication, the patient has suffered side effects, or the recommended cumulative dose has been exceeded.

Depending on the drug, they are administered through a subcutaneous injection (etanercept, adalimumab, ustekinumab, secukinumab, and ixekizumab) or intravenously, in other words, directly into a vein (infliximab). In the case of subcutaneous administration, the patient usually self‑administers the medication at home, while for intravenous treatments, the patient is required to spend a few hours in the hospital.

Treatment complications

Biological drugs are well‑tolerated medicines, with more than 10 years of accumulated experience. Their main side effect is discomfort at the injection site. Since they have an immunosuppressive effect, there is a potential risk of effects deriving from lowered defences.

Some patients develop mild infections like colds, and in some cases there are serious infections such as pneumonia, tuberculosis, or other diseases. Given that the defences play an important role in the fight against tumours, their potential development is being controlled, although so far these drugs have not been shown to increase the frequency (compared to untreated people). On rare occasions, there may be analytical alterations, neurological disorders, heart failure, autoimmune problems, and skin rashes.

For this reason, biological drugs are contraindicated in active infections (including tuberculosis, HIV, and viral hepatitis HCV or HBV), in patients who have cancer or lymphoma, and during pregnancy. Anti‑TNF‑α treatments are also contraindicated in cases where there is a personal or family history of multiple sclerosis, moderate‑to‑severe heart failure, or autoimmune problems.

Substantiated information by:

Felipe Julio Ramirez Garcia
Mercè Alsina Gibert
Paula Aguilera Peiro
Sara Gómez Armayones

Published: 22 February 2019
Updated: 22 February 2019

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