Acquired ichthyosis

The sudden onset of generalized ichthyosis in an adult may indicate an occult malignant tumor, most often lymphoma. In such cases, there is often an associated background erythema, and sometimes pruritus.

Acquired ichthyosis can also be found with leprosy, and in severe nutritional deficiency states.

It can be secondary to cholesterol lowering drugs such as nicotinic acid.
Systemic retinoids can produce an ichthyosis-like condition in some patients.
Acquired ichthyosis should be separated from simple dry skin, xerosis.

Treatment:
Acquired ichthyosis is reversed when the underlying condition is treated.

Acanthosis nigricans

Acanthosis nigricans is a clinical condition consisting of a brown thickening of the skin that is symmetric. Velvety papillomatous plaques with increased skin fold markings, with papillomas, involve the axillae, base of the neck, groins, and antecubital fossa most typically. Other areas, including mucous membranes, can also be involved. Acanthosis nigricans can be secondary to an internal malignant tumor. Such a cancer is usually an adenocarcinoma, most typically gastric carcinoma.

Malignant acanthosis nigricans is usually of sudden onset and is rapidly progressive. Benign acanthosis nigricans can be secondary to obesity, insulin resistant diabetes, Stein-Leventhal syndrome, pituitary tumors, drugs such as nicotinic acid, glucocorticoids, and diethylstilbestrol, or it can be idiopathic.

Treatment
Treatment of the underlying condition results in clearing of the acanthosis nigricans.

Frome http://www.skincareguide.ca/glossary/a/acanthosis_nigricans.html

Abscess (definition)

A localized collection of pus in a cavity formed by disintegration or necrosis of tissues.
(from the ILDS Committee on Nomenclature - R. Winkelmann, Chairman)

Psoriasis: What Should Be Avoided

The following is a list of aggravating factors to avoid if you have psoriasis:

In approximately 1/3 of people with psoriasis, an injury to the skin (for example a scrape, scratch or bad sunburn), can induce psoriasis in the area of the injury. This is called the “Koebner Phenomenon.”
Stress
Alcohol
Smoking
Infections (e.g. Streptococcal infections)
Certain drugs. For example; antimalarials, lithium, beta-blockers, antiotensin-converting, enzyme inhibitors, non-steroidal, anti-inflammatory drugs, iodine, digoxin and clonidine, have also triggered or aggravated psoriasis in certain individuals.

If you are on these medications, speak to your doctor to see if he/she feels that they might be contributing to your condition. Do not stop them without consulting your physician, since it is not always safe to stop them abruptly. If you have a sore throat and suspect a Streptococcal infection, you should see your physician since antibiotic treatment may be required.
Sun Exposure:
Many people with psoriasis notice that their skin improves during the summer or when they travel to southern climates in the winter.

Sun exposure should be done cautiously and in moderation, since the injury from severe sunburn can actually cause the psoriasis to spread all over the sunburned areas. If you are going to be outside for a prolonged period of time, you should use sunscreens.

Treatment Suggestions for Different Types of Psoriasis

Psoriasis treatment choices will be influenced by the amount and location of the psoriasis.

Experience with previous therapy as well as patient preference plays a big part in selecting the most appropriate treatment for each person. Some individuals with minimal disease may be very unhappy with their condition while others with extensive psoriasis seem to accommodate and live relatively unbothered by it. Proximity to treatment centers that offer UV light and day care facilities also influences the options. Patients who have kidney or liver disease will not be good candidates for some of the systemic drugs. Drugs that that you are taking for other diseases must be reviewed to be sure that they do not make your psoriasis worse.

As a general rule, drugs should be used to give maximum benefit, but with minimum side-effects. To achieve this, drugs both topical and oral can be combined together or rotated. This may not only enhance your treatment's effectiveness, but also reduce toxicity by keeping the total dose of each drug as low as possible. Topical therapy is a more demanding option as the extent of the psoriasis increases. Some patients even with large surface areas of involvement prefer to avoid oral drugs.

Plaque psoriasis: (Psoriasis Vulgaris)
Available treatment choices:

Topical:

Mild corticosteroid
Potent corticosteroid
Tars
Anthralin
Calipotriol/calcipotriene
Tazarotene
Calcipotriol + corticosteroid (i.e., Dovobet®)
Systemic:

Acitretin
Methotrexate
Cyclosporine
Light:

UVB
Narrow band (311nm) UVB
PUVA
For Mild - Localized Psoriasis Treatment:
Try topical therapy first. Single or best combination of a different class of drug.

Mild steroid alone
· Mild steroid + one of the following: calcipotriol (i.e., Dovobet®), tazarotene, tar, anthralin
Potent steroid in pulses, for example, on weekends only
Potent steroid + one of the following: calcipotriol, tazarotene, tar, anthralin
Dovobet® can be used as an initial or flare-up treatment. Since Dovobet® is indicated for short-term treatment of psoriasis, it should not be used continuously for extended periods of time because it contains betamethasone dipropionate, a strong corticosteroid. However, Dovonex*® can be used for long-term treatment.

When your psoriasis is extensive or symptomatic:
Topical therapy is always the first option to discuss
Ultraviolet light is most useful when big surface areas are involved
UVB has been used for many years, narrow beam UVB is gaining popularity, although it takes more time, the side effects are likely to be less
PUVA is effective and gives a longer remission, but there is an increased risk of skin cancer - it is used when UVB has not worked
Acitretin can be added to both UVB and PUVA
Methotrexate and Cyclosporine are very effective and can be rotated to minimize accumulative sideeffects
Guttate Psoriasis:
Treat the underlying infection
It is usually extensive, making topical therapy more difficult, tars may help some, especially if combined with a topical corticosteroid, an ointment is often used in a compound of 5-10% LCD (liquor carbonis detergens) with betamethasone 17 valerate 0.1%
UVB is the most helpful first treatment, if that is unresponsive, then narrow band UVB may work
If your psoriasis is difficult and not responding and you are not a woman in the childbearing age range, acitretin can be added
If the options above are unsuitable or your psoriasis is not responding, PUVA can be used
Inverse Psoriasis:
Topical corticosteroids are the most commonly used medications, care has to be taken to avoid skin atrophy
Calcipotriol, tazarotene, anthralin, and tars are usually too irritating
Topical tacrolimus is showing promise, probably because of its ability to penetrate the occluded skin
Pustular Psoriasis:
Localized:

Palmoplantar Pustulosis of palms and soles:

This kind of psoriasis involves the palms and soles, and does not often respond to topical treatment
The following systemic drugs are listed in order of preference:

Acitretin +/- topical PUVA
Methotrexate
Cyclosporine
Generalized:

(Von Zumbusch) Pustular Psoriasis:

You need to remove aggravating factors, such as offending drugs, and tars, you must also take care to taper off systemic corticosteroids slowly
You will need medical support because of the risk of infection, fluid loss, and loss of body heat
You should treat an infection with antibiotics
You will probably need systemic drugs to effectively treat this type of psoriasis
Acitretin is often a doctor’s first choice, Isotretinoin may be used for younger women
Cyclosporine and Methotrexate will also help
Erythrodermic Psoriasis:
In erythrodermic psoriasis, you will see redness and scaling over most of your skin surface.

When you lose the normal protective functions of your skin, it means that medical support is required to maintain body temperature, and fluid and electrolyte balance
Good nutrition is essential, there is a risk of becoming anemic
Be aware that this generalized reaction is often because systemic steroids or potent topical corticosteroids were withdrawn too quickly, infections or burns from phototherapy can also initiate this generalized response
Bed Rest is essential
You should use emollients very frequently
You should use only mild topical corticosteroids (for example, hydrocortisone ointment)
You should be on the look out for infection and shock (record your urine output, BP, and daily weight)
To control this disease you may require systemic therapy
If you are a man, or a woman who is not in the child-bearing age range, you can take acitretin, your doctor should begin treatment at 25mg and increase if necessary
Methotrexate could be initiated at a dose of 15mg weekly, it can be increased
Cyclosporine can be given at a dose of 4-5 mg/kg a day
Maintenance may be achieved with mild topical steroids and/or careful use of UVB
Nail Psoriasis:
This condition is very difficult to treat. Twenty-five percent or more will also suffer from a fungal infection.

A trial of topical corticosteroids especially under occlusion
Calcipotriol may show some benefit in subungual hyperkerastosis
Intralasional triamcinalone, 0.1ml of 2-5mg/ml injected into the nail matrix every 2-4 weeks helps the majority of people with this problem, but in 50% there are quick relapses on stopping
5-fluorouracil 1% twice a day to the nail margins reduces the severity of nail changes in two-thirds of nails over a 3-6 period
Systemic therapy can be of benefit
Psoriatic Arthritis:
Early treatment is recommended to prevent joint destruction
Aspirin and nonsteroidal anti-inflammatory drugs are effective in early stages of psoriatic arthritis
You can use hydroxychloroquine (Plaquanil®) without experiencing a flare of your psoriasis
Gold
Methotrexate can be very beneficial, and may produce long lasting improvement
Newer agents such as the TNF blockers (tumor necrosis factors) are very valuable

Combination Therapy to Psoriasis

Phototherapy + Drugs/Tar/Anthralin
1. Acitretin

It has been widely accepted that combining acitretin with photo therapy either UVB or PUVA is beneficial. PUVA is being used less because of the risk of skin cancers. This has meant that UVB is the most convenient and most commonly used in combination with retinoids for moderate to severe psoriasis which is unresponsive to topical therapy. A low dose of acitretin in the range of 10 to 25 mg daily is started about two weeks before adding UVB. This combination is one of the safest treatments available for moderate to severe psoriasis with no long-term adverse effects documented. Short-term effects of dry skin, thinning of hair and photosensitivity apparently are reduced by lowering the dose of both the retinoid and UVB. The dose of UVB is reduced to avoid photo toxicity. Acitretin when combined with narrow band UVB (311 nanometers) has been shown to be more effective than broad band UVB. Some believe this combination is as effective as PUVA. It is certainly simpler and safer. The long term remission rate may not be as high as PUVA.

2. Methotrexate, Cyclosporine, and UVB

This combination is synergistic allowing a reduction in the total dose of both methotrexate and UVB. There is frequently a rebound on stopping both of these modalities. Cyclosporine can be used in combination with UVB but has not been studied extensively. There is a concern about increasing the risk of squamous cell carcinoma because of the immunosuppressive effect of cyclosporine combined with ultraviolet light.

3. Topical Calcipotriol / Tazarotene

Studies suggest that UVB and Dovonex produces a much greater response than UVB and placebo ointment. UVB twice a week combined with Dovonex was as effective as UVB administered three times a week. The Dovonex should be applied more than two hours before UVB exposure. Tazarotene can be combined with UVB which is particularly useful for resistant lesions. The patients burn more easily because of the thinning effect on the epidermis produced by the tazarotene. UVB doses are usually reduced by up to one third when tazarotene is used in combination.

4. Tar and Anthralin

The Goeckerman regime is still one of the most effective treatments for clearing psoriasis. This is combining tar with UVB. The Ingram regime uses anthralin and UVB. Short contact tar and anthralin when combined with UVB can produce remission in about 70 percent of patients which can be maintained for about six months.


From http://www.psoriasisguide.com/psus_treat/combination_therapy.html

Light Therapy to Psoriasis

Light therapy (phototherapy) is given under the supervision of a physician. It is available in dermatologists’ offices, psoriasis day-care centers, phototherapy clinics, and some hospitals.

UVB:
Ultraviolet B (UVB) light waves have wavelength’s ranging between 290-320 nm. It is the wavelength in sunlight which is responsible for most of the sunburns; sometimes tar, anthralin, calcipotriol/calcipotriene, or tazarotene topical therapy is also used in conjunction with UVB phototherapy. In 1925, Goeckerman used tar in addition to UVB, the Ingram method refers to tar baths, topical anthralin, and UVB.

UVB is given to the whole body in a cabinet, or to localized areas with a small portable unit. Most UVB given is broadband UVB. Narrow band UVB, which has a wavelength of 311 nm, is available in certain centers. Some patients may do better with narrow band UVB, but the risk of a sunburn reaction may be greater.

The eyes need to be protected with special glasses during UVB treatment in order to prevent eye damage. Although treatment is often limited to 2-4 weeks, long term treatment might be associated with aging of the skin, burning, and potentially an increase in skin cancer. UVB is usually administered three times a week for three months for clearing and maintenance can be achieved by using it less frequently. Long remissions may occur after UVB phototherapy.

The mechanism of action is unknown. It may reduce synthesis of DNA within epidermal cells and alter the immune response in the skin. It is less effective than PUVA but can be improved by adding other systemic therapies. The onset of response is slow.

Narrow Band UVB:
This is seen to be more effective than UVB. It can cause freckling and changes of skin aging. It takes longer to administer narrow band versus regular UVB.

PUVA:
PUVA stands for Psoralen (a medication that sensitizes your skin to ultraviolet A light waves) + UVA (ultraviolet A, with a wavelength range of 320-400 nm). The psoralen may be taken internally as a pill or applied to the skin (in bath water or as a cream, ointment, or lotion). After a set time after the psoralen has been taken or applied, the skin is exposed to ultraviolet A radiation in a cabinet or with a small portable unit.

You must wear protective eye glasses as soon as you take the psoralen pill during treatment (for both the internal and topical PUVA treatments), and for one day after your treatment, in order to prevent eye damage. Other potential side effects include itching and dryness of the skin, a sunburn reaction, freckling, aging of the skin, and skin cancer. The pill often causes an upset stomach. You can minimize nausea by taking the psoralen pill with food. PUVA therapy is usually given initially 2 to 3 times a week, then less frequently as the skin improves. It takes about 25 treatments over a 2-3 month period before clearing takes place. Long remissions may occur after PUVA therapy. Maintenance of improvement can in some be achieved by much less frequent use.

Phototherapy is useful when the psoriasis is generalized. It is effective and may have an ability to turn off the psoriasis for months. It can be used in combination with both methotrexate and the retinoids. The disadvantage is the increased risk of squamous cell carcinoma as well as melanoma. Photo damage with freckles and lentigines are seen particularly with PUVA.

The mechanism of action is unknown but involves the interaction of methoxsalen into DNA forming cross links. This results in the reduction of DNA synthesis and blocks cell proliferation. It may also suppress immune response in the skin.

The efficacy is very significant in a large percentage of patients. The duration of effect is long but the onset of improvement is slow.

Re-PUVA:
Re-PUVA refers to treatment with a retinoid (for example, Acitretin) and PUVA. The retinoid is usually started a couple of weeks before the PUVA. The total dose and number of PUVA treatments may be less if treatment with a retinoid is also given.

Laser:
Laser light treatment has been used for localized resistant patches with some success. However, it is still considered experimental. The laser used is the 308nm Eximer® laser which gives a quick response. Since the light beam is relatively small, it is not a practical treatment option for generalized disease.


From http://www.psoriasisguide.com/psus_treat/light_therapy.html

Alefacept (Amevive) IM administration

In October 2004 Amevive® (alefacept) became the first biologic approved for psoriasis in Canada. It is marketed for the treatment of patients with moderate-to-severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy.

This is a LFA-3 fusion protein. The cell surface domain of LFA-3 is fused to the Fc part of the human IgG molecule. This drug blocks the interaction between the CD2 receptor on a Tcell and LFA-3 receptor on the antigen presenting cell. It also interferes with the reaction between T-cells and natural killer cells which results in reduction of the number of activated memory T-cells in circulation. The drug selectively targets the activated memory T-cells rather than the naïve T-cells. This drug uses its cell-bridging ability to selectively induce death of specifically activated lymphocytes called CD4+ and CD8+.

Clinical Trial
Clinical trials have been conducted using both intravenous administration as well as intramuscular. The results were very similar in terms of efficacy. For a practical point of view the intramuscular injection only will be discussed as this is the preferred choice of administration by patients. Typically the drug will be injected intramuscularly once a week over a twelve week period. The measurement of improvement is measured by the PASI score which takes into account the surface area of psoriasis involved as well as the severity of the individual lesions in terms of thickness, redness and scaling. This is a standard measure of improvement. In a typical study the patients were given 15 mg intramuscularly once a week. The results showed twenty-four patients with almost total clearing, thirty-three showed a greater than seventy-five percent reduction in their PASI score and fifty-seven showed greater than fifty percent reduction. Patients are also asked to evaluate the results using the Dermatology Life Quality Index (DLQI). This is a questionnaire on the impact of disease on quality of life. Interestingly, patients with seventy-five percent reduction in PASI are as happy as those who are completely clear. Those patients with a fifty percent reduction in their PASI score also showed significant diminution in their quality of life measurement. The improvement in quality of life scores were at least sixty percent even in those who showed a fifty percent reduction in their PASI.

Duration of Response
It is very pleasing and significant to see that the improvement persisted well after discontinuing therapy.This is a very strong factor in favour of this drug. Significant improvement was maintained for over twenty-two weeks after discontinuing therapy. The median time before retreatment was required was ten months.

Dosing
The studies were of a twelve week duration. The patients were followed for a further twelve weeks. A second course was given in the same manner as the first after twelve weeks. The second course gave additional improvement. Doses ranged from 7.5 to 15 mg weekly. New studies looking at different dose duration are underway

Side Effects
About five thousand patients have been treated to date. The safety profile is very good for this drug. There has been no evidence of any increased risk of infection despite the lowering of the T-cell count (CD4+ observed in some patients).Weekly T cell counts are done. There is no need to check liver or kidney fuction

Ten percent of patients observed chills. There is a small increased incidence of sore throats.

A problem with some of the biological drugs rebound of the disease after stopping medication. This was not observed with alefacept.

Candidates for Alefacept
It is thought that at least ten percent of patients with moderately severe psoriasis and not responding to the current therapy or have from side effects that limit the continuation of therapy with the specific drug Some patients have run out of safe therapeutic options. There is a frustration also that many patients will not achieve a lasting improvement from their therapy. The toxicity of other treatments are a consideration when selecting a new therapy.

Drug Interactions
This drug should not be used in combination with other immunosuppressants until there is further experience.

A major challenge will be to find the ideal combination therapy perhaps using phototherapy such as narrow band UVB in order to extend the durability of the clinical response. This can be combined with the use of emollients and topical anti-psoriatic medication for early application to any relapsed area of skin.

Alefacept has received approval for moderate to severe psoriasis by the FDA.


From http://www.psoriasisguide.com/psus_treat/immunobiologics/alefacept_amevive.html

Biologic Drugs and How They Work

We are entering a very exciting stage in medical treatment in that drugs have been designed to specifically hit immunological targets that are involved in specific conditions. Previous immune therapy has involved drugs that have a general suppressing effect on the immune system which consequently prevents high doses being used because of the fear of side effects. Theoretically the more specific the target to be blocked, the less interference with other biological functions - making the drug safer.

These new drugs are known as biological drugs. They are created in living cells. The technique has been used for a long time for drugs such as insulin or interferon.

There are a number of new biologic drugs that are currently used in psoriasis.

Alefacept (Amevive)
Efalizumab (Raptiva)
Inflixiamab (Remicaide)
Etanercept (Enbrel)
Explanation of the difficult drug names:
The suffix denotes the drug class.

Mab = monoclonal antibody

Ximab = chimeric(mouse-human) monoclonal antibody

Zumab = Humanized monoclonal antibody-ie. Reducing the amount of mouse to under10%

Umab = Human monoclonal antibody

Cept = receptof –antibody fusion protein that mimics an immunoglobulin

These drugs can target different steps in the pathway of producing psoriasis. The following general targets have been identified and can be blocked.

T-cell activation
Inhibiting memory or activated T-cells
Blocking the migration of T-cells into the skin
Inhibiting the chemicals or cytokines produced eg. tumor necrosis factor
Blocking conversion of one cytokine into another

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From http://www.psoriasisguide.com/psus_treat/immunobiologics/biologic_drugs.html

Immunobiological Treatment in Psoriasis - An Overview

Psoriasis is an inflammatory condition the cause of which is unknown at this time. There is certainly a genetic component to this condition and work over the last decade or so has shown that it is an immunological disease. It has long been known there is inflammation within the plaques of psoriasis. A chance observation that an immunosuppressive drug called cyclosporine used to prevent rejection in individuals with organ transplants cleared psoriasis. This showed that white blood cells called lymphocytes were important in the production of psoriasis, More recently a huge amount of work has defined many of the immunological events involved in psoriasis. Interestingly, the immune response may have strong similarities to that which occurs in patients with rheumatoid arthritis, Crohn’s disease and possibly multiple sclerosis.

There is an immune activation of white cells called lymphocytes. The type of lymphocytes called T-cell lymphocytes are activated and in turn produce chemical mediators known as cytokines. These cause the cells within the epidermis to grow quickly. Lymphocytes are part of the defense system and are in a sense the paratroopers of the immune system which attack a variety of antigens such as viruses. The skin is very active in the immunological organ which explains why we develop rashes as a result of allergic reactions to multiple substances including medications. Part of the life history of a T-lymphocyte is that it is produced in the bone marrow and travels through lymph nodes and makes a journey through the skin - particularly the epidermis. An antigen is something such as a protein that we have an immune response to. Before this can happen there are specific cells whose function are to present antigens to lymphocytes and some of them live within the epidermis.

Once a lymphocyte has been introduced to an antigen it becomes activated and it becomes a specialist against a specific target. The antigen or the target for the immunologic attack in psoriasis is not known but it is clear that activated lymphocytes that are an important part of the process of making psoriasis. The interaction between the lymphocytes and the cells that introduce the antigen and the cytokines that are produced is very complicated. Cytokines are chemicals such as interferon, interleukin or tumor necrosis factors. Luckily for us these activated lymphocytes will stay on the job of attacking something within the epidermis and do not go off to other parts of the body to cause inflammation. They do not prevent other lymphocytes from being available to fight colds and other infections.

The discovery of the interactions between these cells and the specific receptors on the cell urfaces as well as the chemicals that they release has given scientists an opportunity to develop drugs that block this cascade of activity at different points.

From http://www.psoriasisguide.com/psus_treat/immunobiologics/immunobiological_treatment_psoriasis.html

Oral Treatment to Psoriasis

Methotrexate:
Methotrexate is usually given once a week orally (pills) at doses ranging from 2.5 to 25 mg. or occasionally by injection (with a needle). It can be administered either as a single dose or in a split dose twelve hours apart for three doses. It helps control psoriasis affecting your skin, nails, and joints. The mechanism of action is the interference with DNA synthesis repair and cellular replication. It has an immunomodulatory effect.

Twenty-six percent of patients achieve a PASI (Psoriasis Area and Severity Index) 75 response at twenty-four weeks. The onset is usually between four and six weeks.

Side effects include upset stomach, mouth ulcers and tiredness. Long-term risks include liver damage, birth defects, bone marrow toxicity and suppression of the bone marrow with low blood counts. Careful monitoring by your physician is essential on this medication. Liver biopsies may be required. It is contra-indicated in liver disease and alcoholism.

Acitretin (Soriatane):
Acitretin is a retinoid with properties similar to vitamin A. For most patients, it does not appear to be as effective as methotrexate or cyclosporine in the treatment of plaque psoriasis. However, it works quite well for pustular psoriasis. It is used mainly in men, and women who are post-menopausal or have had a hysterectomy.It is not used in women of child bearing age because of the risks of birth defects. Monitoring by your doctor and regular blood tests are required while taking this medication.

The mechanism of action is unknown. It inhibits cell replication by modulating cellular differentiation within the epidermis.

It works slowly and the onset of response is usually two to four months. It is not as effective when used as monotherapy but can be combined with photo therapy as well as the new biologics. It is helpful particularly for palmar plantar psoriasis.

Side effects include dryness of the skin, lips, eyes, and nose. Elevation of the cholesterol and triglyceride levels liver toxicity and bone changes, since it may cause birth defects. Safety concerns include hyperlipidemia and alopecia. Depression and psychiatric symptoms such as aggressive behaviour and thoughts of suicide have been reported. It is usually administered daily at a dose of 10 or 25 mg. The frequency of taking this drug is often reduced to two or three times a week at least initially.

Cyclosporine (Neoral):
Cyclosporine is an immunosuppressant psoriasis medication used in organ transplantation. It is very effective, but because of its cost and side effects (kidney toxicity, high blood pressure, numbness and tingling, hair growth, skin cancer and lymphomas), it is usually reserved for people with severe, disabling, resistant disease. Monitoring required by your doctor while taking this medication includes blood pressure, creatinine and urea.

This acts on T-lymphocytes. It is specific and reversible inhibition of active T-lymphocytes.

About eighty percent of patients achieve a PASI (Psoriasis Area and Severity Index) 75 response at twelve weeks after discontinuing therapy. The disease usually returns within seven weeks. The rate of onset of response is quick and often is seen within four weeks.

It is usually administered once to twice a day orally.

From http://www.psoriasisguide.com/psus_treat/oral_treatment.html

Topical Treatment to Psoriasis

Topical psoriasis treatment includes corticosteroids, calcipotriol/calcipotriene, tazarotene, tars, and anthralin. Tars and anthralin are discussed above.

Calcipotriol and Betamethasone Dipropionate (Dovobet®)
Calcipotriol is safe and an effective treatment for psoriasis when used along but the onset of action is slower than that of topical corticosteroids. Skin irritation may also limit its use for some patients. Topical steroids are effective for the treatment of psoriasis by reducing the inflammatory process. The risk of side effects increases with increasing potency of the steroid as well as the duration of their use.

Combining both corticosteroid and calcipotriol has been shown to be effective. However, extemporaneous compounding of these products is a problem because of stability issues. Calcipotriol needs a basic pH environment whereas betamethasone dipropionate requires an acidic medium. A new vehicle was created in order to satisfy the needs of both of these molecules. This combination product is available in Canada as Dovobet®.

Studies show that Dovobet® is more effective than calcipotriol or betamethasone dipropionate alone. In one clinical trial, after 1 week of treatment, the percentage of reductions in PASI scores were 28% in the calcipotriol trial group, 44% in the betamethasone group and 48% in the Dovobet® group.

Dovobet® is as effective when used once daily compared with twice daily. In addition to the adverse effects which may be seen with calcipotriol and topical corticosteroids, Dovobet® is known to cause itching at the site of application. The itching is usually mild with no need to stop treatment. For patients that have been prescribed Dovonex* or Dovobet®, you can access more product information by clicking either of these links and entering the DIN Number from your prescription: www.dovobet.ca or www.dovonex.ca.

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 extensively, but at dosages of less than 100 gm per week calcium metabolism is not affected. Since it may cause irritation, calcipotriol is not usually used on the face, genitals, or in skin folds.

This can 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.

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%
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 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.


From http://www.psoriasisguide.com/psus_treat/topical_treatment.html

OTC Treatment for Psoriasis

Moisturizers:
Moisturizers help control scaling and dryness and may improve associated itching. They should be applied immediately after bathing and at other times during the day. Moisturizers should be applied in the direction of the hairs to minimize the risk of pimple like eruptions. Vaseline®, Eucerin® and Aquaphor® are all occlusive sticky products that can be of benefit.

Tars:
Tars are available as shampoos, soaps, gels, lotions, creams, ointments, and bath oils. Coal tar has been used since at least the beginning of the last century. These products can be combined with topical corticosteroids. These products make the skin sensitive to ultra violet-A light waves (UVA). They are often used in combination with ultra violet-B light waves (UVB). Folliculitis can be a side effect.

Tar shampoos are commonly used to treat scalp psoriasis however, they may discolor white hair turning it a yellowish color. Side effects are related to skin irritation and staining of skin and clothing.

They also tend to have an unpleasant odor.

Salicylic Acid:
Salicylic acid moisturizers and shampoos help remove some of the scales seen in psoriasis, it may be useful in reducing the thickness of psoriatic scale, but care must be taken to be gentle to the skin to prevent flaring of the psoriasis. It may be combined with tar, anthralin, and topical corticosteroids.

It is true that compounding calcipotriol and salicylic acid is not recommended because calcipotriol could be inactivated in an acidic environment. However, application of salicylic acid to the skin does not influence skin surface pH enough to influence the stability of calcipotriol in its in vivo situation. A combination treatment of Dovonex* and Psorimed® (10% salicylic acid, marketed by LEO Pharma in Germany) is actually recommended for the treatment of scalp psoriasis: Dovonex* is used in the morning and salicylic acid in the evening for the first 3-4 days; or salicylic acid is applied for 3-4 days followed by Dovonex* twice daily with no expected special risk of accelerated calcipotriol breakdown.

Other Shampoos:
There are many over the counter dandruff shampoos which can improve scalp psoriasis, particularly the scaling. They include the tar and salicylic acid shampoos listed above, ketoconazole and zinc pyrithione also.

Hydrocortisone Cream:
Hydrocortisone cream may improve psoriasis on the face and in the skin folds and improve itching. A stronger prescription topical corticosteroid is usually required to improve psoriasis lesions elsewhere.

From http://www.psoriasisguide.com/psus_treat/over_the_counter_treatment.html

Quality of Life Assessment in Psoriasis

In choosing which type of treatment should be applied, it is important to try and define who should be treated with what medication, and specifically with the new specific drugs that are available. Severity on pure surface area is not an adequate enough determination and clearly the impairment of quality of life has to be incorporated into the decision. An interesting and helpful position paper from the Medical Advisory Board of the National Psoriasis Foundation suggested three different categories.

Mild: Disease that does not alter Quality of Life


Moderate: Disease that alters Quality of Life. Therapies would be expected to improve Q of L with minimal risk of side effects


Severe: Disease that does alter Quality of Life and the response to treatments which have minimal side effects has been ineffective. These patients will accept life altering side effects to achieve better Quality of Life.


Psoriasis can have a significant impact on a patient’s quality of life - sometimes profoundly altering their everyday life.

There are a number of surveys that have been designed. Some are very specific for psoriasis itself while others are dermatology specific. Yet others will compare diseases not affecting the skin as a comparison of disease impact. At least four specific psoriasis questionnaires have been developed. The psoriasis life stress inventory is a fifteen item tick box questionnaire involving the impact of psoriasis on the previous month’s quality of life. The psoriasis quality of life questionnaire developed on a population based survey where there are twenty-two items specifically on the impact of psoriasis and nineteen regarding day to day living.

The Psoriasis Disability Index
This is a questionnaire addressing fifteen aspects including daily activities, personal relationships, vacation, work as well as the effects of actual treatment. This has been used in a number of clinical studies.

The Dermatology Life Quality index was used as a measure of improvement in studies with alefacept (Amevive). This is a questionnaire relating to the previous week’s activities and feelings. Work, school, leisure, daily activities as well as the symptoms and feelings are measured as well as personal relationships and the impact of treatment.

A Quality of Life patient survey published in the Archives of Dermatology in 2001 showed interesting results. The survey of the US National Psoriasis Foundation of 40,350 patients when over 17,000 responded. The information from this suggests that physicians underestimate the disease severity.

78% of severe psoriatics: frustrated by the lack of efficacy of treatment
26 minutes: average time to apply topical medications per day
In a quality of life survey published in the Journal of the American Academy of Dermatology (1999;41 pages 401 to 407) the publication showed a comparison with negative impact on physical and mental aspects of life comparing various conditions. The score of 1 had little impact and the score of 11 had a great impact.

6: arthritis
8: chronic lung disease
11: congestive heart failure
9: diabetes
10: psoriasis
In terms of impact on the mental component:

11: depression
10: chronic lung disease
5: chronic heart failure
9: psoriasis
Further information from quality of life surveys suggest that 78% of psoriatics indicate the negative impact of their life quality whereas 21% of patients suggest neither a positive or negative effect.

PASI - The Psoriasis Area and Severity Index
The National Psoriasis Foundation physician forum in the summer of 2002 suggested a scale by which patients could indicate improvement or worsening of their condition and specific treatments. At the baseline visit a patient was asked to rate their psoriasis on a scale of 1 to 10 with 10 being the worst episode of psoriasis ever and 1 as being completely clear. This is a practical way of dynamically assessing the patient’s perception and can be used in combination with the physician assessment of PASI. This is the Psoriasis Area and Severity index.

This measures surface area which is broken into the head, upper extremities, trunk and lower extremities. The lesions are given a score for redness, thickness and scaling. A formula is then applied to give a score which can be used for following improvement or worsening during a clinical trial.

PGA - The Physician Global Assessment Scale
Another means of assessing is the physician global assessment scale (PGA). This is the physician’s assessment of the psoriatic plaques. This is a seven point scale with 7 being clear and 6 almost clear, 5 mild, 4 mild to moderate, 3 moderate, 2 moderately severe and 1 being severe psoriasis. More work needs to be done on refining the tools for measuring the impact of psoriasis on an individual. This is very important as it can be used as a tool of measuring the impact of treatment on the patient.

The Goals Of Psoriasis Treatment Include:
Improvement of the physical signs and secondary psychological effects
Reduction of inflammation and control of skin shedding
Control of the physical signs for as long as possible
Avoidance of factors that can aggravate the condition