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