The treatment of psoriasis should be based on shared decision between patients and their doctors. Patients should be given adequate information regarding their disease and current available treatment options. The goal of treatment is to improve and maintain patients’ quality of life through control of symptoms and signs of psoriasis. Implementing and regular monitoring of treatment goals based on disease severity and patients’ preferences are necessary to ensure long-term effective treatment and to prevent complications from uncontrolled disease activity. The choice of treatment should be individualized based on patient’s disease severity, patient’s preference, availability of treatment and the risk-benefit of treatment.

Modalities of Treatment for Different Types of Psoriasis

There are various treatment modalities available for psoriasis depending on the type of psoriasis, disease severity, patient’s preference, availability of treatment and the risk-benefit of treatment. Treatment options currently available include topical treatment, systemic treatment, phototherapy and biologics.

Topical therapy is generally indicated for mild to moderate disease. However, even patients with extensive psoriasis can be effectively treated with topical therapies provided patients are compliant to their treatment. Topical therapies that are currently available in Malaysia include moisturizers¹ for skin dryness, tar-based preparations² for the thick and scaly skin lesions, corticosteroids³ to reduce inflammation, vitamin D analogues⁴ such as calcipotriol to also reduce inflammation, calcineurin inhibitors⁵ such as tacrolimus for psoriasis affecting the face and skin folds, and salicylic acid⁶ to thin the thickened lesions (keratolytic) (Photo 1).

Photo 1: Various topical treatment

Phototherapy^7,8 is indicated for patients with moderate to severe chronic plaque psoriasis. It includes ultraviolet A (UVA), ultraviolet B (UVB), red light, blue light and excimer laser. UVA is delivered in combination with a photosensitizing agent (psoralen) in oral, topical or bath form. UVB is delivered as narrowband (NBUVB) or broadband (BBUVB) (Photo 2). Patients need to undergo 2-3 sessions of phototherapy per week.

Photo 2: Phototherapy cabin

Patients with moderate to severe psoriasis frequently require systemic or biologic therapy. Systemic agents such as methotrexate⁹, acitretin¹⁰ and cyclosporine¹¹ have possible significant side-effects and cumulative toxicity. Therefore, pre-treatment assessment of patients is important to identify those at risk of developing toxicity. Laboratory/imaging tests should be done at baseline and at regular intervals to monitor for side effects/toxicity.

There are strong and consistent evidences on the efficacy of biologics in the treatment of moderate to severe plaque psoriasis¹². Biologics such as infliximab, adalimumab, ustekinumab and etanercept are bioengineered proteins designed to block specific molecular steps important in the pathogenesis of psoriasis. However, biologics are associated with adverse events of which some are serious and life threatening. These include opportunistic infections, reactivation of tuberculosis, malignancy, congestive heart failure, demyelinating disease, injection/infusion reactions, hematological disturbances and liver toxicity. All current available biologics are administered with injections.

Source: Open access, Google Images

Treatment of psoriasis in pregnant patients that are considered relatively safe include moisturizers, topical corticosteroids, UVB phototherapy, oral cyclosporine and systemic corticosteroids.

How to Maximize Effects of Treatment

Patient adherence to the treatment regime prescribed by their doctor is the key component in ensuring they receive maximal effects of treatment. Implementing and regular monitoring of treatment goals based on disease severity as well as monitoring side effects and toxicity of treatment, are necessary to ensure long-term effective treatment and to prevent complications from uncontrolled disease activity.

Why is Systemic Steroids Discouraged?

The use of systemic steroids is discouraged because of several reasons:

Reference

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