Most times, it is quite easy to identify those patients with psoriasis who have severe disease, and thus the decision to commence systemic treatment is relatively straightforward.
Pustular psoriasis affecting the hands and feet can be disabling. When it involves prominent areas on the face, it can be cosmetically embarrassing, and can lead to psychological and employment problems.
There are those types of psoriasis, such as erythrodermic and generalised pustular varieties, which can even by life threatening.
Some patients with widespread involvement may not be too worried about their disease, and yet other patients can be very upset by even small patches of psoriasis, especially when it is itchy. Due to the potential short and long term side effects with most of the available systemic treatments, and the fact that none of these treatments can offer permanent cure, the decision to switch from simple topical treatment options to systemic modalities is not always straightforward. Patient education and involvement in the decision is important.
The range of potential treatment options can be divided into the following categories:
- Phototherapy
- Oral retinoids
- Conventional immunosuppressive medications
- Biologic agents
In most instances, topical treatment should be continued in addition to systemic therapy.
The main problem with phototherapy (narrow band UVB or PUVA) is that of inconvenience for the patient. Treatment is administered 3 times a week. Commonly, patients are unable to undergo this form of therapy because of work commitments, eventhough it can be very effective. The other concerns with long term light therapy include the risk of skin cancers (both non-melanoma as well as melanoma) and premature aging of the skin (photoaging).
Oral retinoids, in particular oral acitretin (Neotigason), can be very effective in patients with chronic plaque psoriasis. It can take a few months for maximal response to the drug, although combining treatment with narrow band UVB can accelerate this. The main problem with this drug is that it cannot be used in women of child bearing age, as pregnancy is contraindicated through to 3 years following cessation of treatment.
The next group of systemic agents can all be described as immunosuppressants. Methotrexate and cyclosporine are the immunosuppressants most commonly used in Australia. Of these two, methotrexate is often favoured because of its better safety profile, especially over long term use. However, when rapid control of very severe psoriasis is needed, cyclosporine can be very useful. After cyclosporine use, patients can be switched over to either methotrexate or acitretin for maintenance therapy.
In those patients who have tried and failed, or who are unable to tolerate the above mentioned systemic treatments for severe psoriasis, the biologic agents are an exciting new option for treatment.
This biologic group includes the TNF-inhibitors: infliximab, adalimumab and etanercept. Another biologic agent, Efalizumab was recently withdrawn from the market because of several cases of progressive multifocal leukoencephalopathy. Although these drugs can have a very dramatic effect on a patient’s disease, they are still not a cure. As the case of efalizumab illustrates, there is probably still a lot we do not know about future complications for these drugs. Nonetheless, they offer new hope to patients who otherwise have to endure very severe disease.
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