WHAT ARE THE TREATMENTS FOR PSORIASIS?

[peterb]

Systemic treatments involve oral or injected drugs, which affect the entire body. Many of the systemic drugs used for psoriasis are also used for other severe diseases, including autoimmune diseases (especially rheumatoid arthritis) and cancer. Nearly all are powerful medications with potentially serious side effects. These drugs should be used only for severe incapacitating cases of psoriasis that do not respond to lifestyle changes or topical (or other less potent) therapies.

As with all agents used for psoriasis, the least potent agents should be used first:
Methotrexate and retinoid are the first-line, or primary, oral drugs for adults with severe psoriasis. Cyclosporine may be considered as first-line therapy for children with severe psoriasis.

Second-line drugs include hydroxyurea, sulfasalazine, and thioguanine.

Third-line agents include tacrolimus.
 
Methotrexate
Methotrexate (Rheumatrex) is very effective for severe psoriasis. For example, one center reported that 80% of patients reported prolonged improvement. It has the following beneficial properties:
It interferes with cell reproduction.

It has anti-inflammatory properties.

It is one of the few systemic agents proven to help patients with psoriatic arthritis.
It is important to note that the recommended dose is taken weekly, not daily. Fatal toxicities have been reported in people who mistakenly took it once a day.

Side Effects.
Common side effects of methotrexate are nausea and vomiting, rash, mild hair loss, headache, and mouth sores. It may also cause muscle aches. (Many of these symptoms are due to folic acid deficiency. Patients should ask their physician about supplements to offset these symptoms.) Patients who experience nausea may opt for injections, which are effective and less expensive than oral agents.
More serious complications include the following:
Kidney abnormalities and liver scarring. People at particular risk for liver damage from methotrexate include diabetics with existing liver or kidney problems, alcoholics, those who are obese, and the elderly. Regular monitoring for liver toxicity is important.

Suppression of blood cell production in the bone marrow.

Osteoporosis.

Increased risk for infections, particularly herpes zoster and pneumonia.

Lung disease occurs in up to 5% of people who take methotrexate and deserves special mention. There are five key risk factors for methotrexate-induced lung diseases: age, diabetes, existing rheumatoid involvement in the lung, protein in the urine, and previous use of other DMARDs, particularly sulfasalazine, oral gold and d-penicillamine. Patients with multiple risk factors should report any symptoms, such as coughing, that might indicate lung injury.

Severe anemia from folic acid deficiencies. Supplementation with folic acid while taking methotrexate can prevent this side effect.

There have been a few reports of lymphomas in some patients taking methotrexate; in such cases, the disease appears to go into remission when the drug is stopped. Most studies have found no significant risk for cancer in patients taking this agent.

Patients taking methotrexate should not take nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil), or naproxen, which can cause serious toxic interactions. (It should be noted that rheumatoid arthritis patients who take methotrexate often also take NSAIDs, but methotrexate doses for psoriasis are usually much higher.) Patients should ask their physicians about any other drug interactions.
Pregnant and nursing mothers should never take this drug, which increases the risk for severe, even fatal, birth defects and miscarriage. Other people who should avoid methotrexate are those with psoriasis who also have impaired immune systems, peptic ulcers, active infectious diseases, rheumatoid arthritis, or anemia or other blood abnormalities. Methotrexate appears to be effective in children, but more safety research is needed.
 
Oral Retinoids
Oral retinoids (derivatives of vitamin A) include etretinate (Tegison), acitretin (Soriatane), and isotretinoin (Accutane). Acitretin is the retinoid of choice and is effective for severe psoriasis, particularly pustular variants. Etretinate is useful for patients who are HIV positive. Accutane is sometimes used but is far less potent than acitretin.

Benefits. Oral retinoids have the following beneficial properties for patients with psoriasis:
They have anti-inflammatory actions.

They help regulate cell reproduction.

They may even improve arthritis that accompanies psoriasis.
Combinations. Many experts now believe that acitretin is not very useful as a single agent but can be very effective in combination with other agents, usually topical agents and especially with phototherapy. Acitretin and phototherapy, in fact, have some of the highest clearance rates of any treatment. In addition to combination treatments, some experts recommend the following to reduce toxic effects of acitretin:
Maintenance doses should be as low as possible and should be taken every second or third day.

Patients aim for a low-fat diet and engage in daily aerobic exercise to maintain healthy triglyceride levels.

Fish oil supplements may be very helpful.
Side Effects. Children and women who wish to bear children should not take these agents. All retinoids have the same potentially serious toxicities as do high doses of vitamin A:
Common side effects include dry nose, dry eyes, chapped lips, bone and joint pain, thinning hair, fatigue, peeling of the palms and soles, nose bleeds, bruising, and headache.

Of special note, retinoids pose a significant risk for birth defects when taken by pregnant women. [See Box Retinoids and Pregnancy.]

The drugs may cause eye problems, including blurred vision, cataracts, and a sudden deterioration in night vision.

Retinoids carry a high risk for increased bone growth, particularly in the ankles, pelvic area, and knees.

They increase triglyceride levels, which are proving to be significant risk factors for heart disease.

In rare cases, they may cause a condition called benign intracranial hypertension, which occurs in the brain. Symptoms include headache, nausea, vomiting, and blurred vision. Patients experiencing these symptoms should call the physician immediately and stop taking the drug.

The drugs also can cause damage to the liver.

Oral Retinoids and the Pregnant Patient
Retinoids taken by pregnant women pose a significant risk for severe birth defects in the unborn child. Pregnant or nursing women should not use either acitretin or etretinate, although there are some difference.

Etretinate. Etretinate is stored in fat cells for up to three years, so women should not become pregnant for at least that long after discontinuing the drug.

Acitretin. Acitretin is cleared from the body more rapidly than etretinate and becomes undetectable in about three or four weeks, so it appears not to pose a long-term risk for birth defects.

There is one important exception: Drinking alcohol converts acitretin to etretinate. Therefore, if a woman drinks alcohol while taking acitretin or any time during the two months after she stops, she must wait three years to conceive.  

Cyclosporine
Cyclosporine. Cyclosporine (Neoral, Sandimmune, SangCya) blocks certain immune factors and is known as an immunosuppressant. Neoral is the preparation used most often for psoriasis. Studies report that it clears psoriasis in between 60% and 80% of patients within eight to 12 weeks. A new microemulsion formulation (Neoral-Neo) may be safe for patients with erythrodermic psoriasis. It can be used alone or in combination with topical agents in certain circumstances.

It has significant side effects, and should be reserved for patients who did not response to phototherapy or less potent systemic agents (eg, methotrexate or acitretin). Side effects include the following:
Common and temporary side effects. Headaches, gingivitis, joint pain, gout, body hair growth, tremor, and fatigue.

High blood pressure (occurring in up to 30% of patients). Some experts advise treating any high blood pressure with calcium-channel blockers, since other standard anti-hypertensive drugs may worsen psoriasis.

It increases the risk for unhealthy cholesterol and lipid levels.

Prolonged use always causes some kidney damage.

It causes abnormalities in the liver.

Because it suppresses the immune system, cyclosporine also increases the risk for infections.

Long-term use may increase the risk for skin cancers and lymphomas, particularly in patients who have had other psoriasis treatments, including PUVA, tar, or radiation therapy, methotrexate, or other immunosuppressant drugs.

Cyclosporine interacts with many drugs, including some over-the-counter preparations. Patients should discuss all medications with their physician. Grapefruit and grapefruit juice contain psoralens, which can increase concentrations of the drug, and should be avoided.
Patients should be monitored regularly for hypertension and signs of kidney or liver abnormalities. To minimize complications of cyclosporine, the dosage is reduced after improvement occurs. Maintenance therapy is usually limited to a year, although some experts say that the microemulsion form of Neoral is safe for up to two years.
 
Second- and Third-Line Systemic Agents
Second- or third-line agents are used alone or sometimes in combination with first-line systemic drugs if they fail. They are generally less safe than first-line agents.

Hydroxyurea. Hydroxyurea (Hydrea) appears to inhibit cell reproduction and also increases water content in red blood cells. The drug can lower blood cell counts, causing anemia and possibly increasing the risk for infection. Other side effects include gastrointestinal problems, leg ulcers, and skin rash. In some patients it may cause dark coloring of the nails. Pregnant or nursing women should not use it. Thioguanine. Thioguanine (Tabloid) is an immunosuppressant used in cancer treatments and has actions against T-cells. Small studies are reporting it to be effective for patients with moderate to severe plaque psoriasis. In a small 2001 study, 78% of patients reported dramatic improvement (90% or greater clearing of their lesions) during 15 months of treatment. This drug suppresses blood cell production and can cause liver and gastrointestinal damage, although the risk does not appear to be significant in psoriasis patients.

Azathioprine. This agent may be helpful in allowing a lower dose of cyclosporine.

Sulfasalazine. Sulfasalazine (Azulfidine) was developed in the 1930s for treating rheumatoid arthritis and is sometimes used for psoriasis. In one major analysis, sulfasalazine and methotrexate were the only agents proven to help patients with psoriatic arthritis.

Zidovudine. Zidovudine, also known as AZT, may be effective for patients with AIDS-induced psoriasis. Studies have found that it helps improve the condition in cases of severe pustular psoriasis that does not respond to etretinate.

Mycophenolate mofetil (MMF). MMF has been disappointing and some experts recommend it only as an added drug in patients who do not respond to methotrexate or cyclosporine.
Biologic Response Modifiers
Biologic response modifiers are genetically engineered drugs that interfere with specific components of the autoimmune response. Because of their precise targets, these drugs do not damage the entire immune system the way that general immunosuppressants do. They are the first agents to produce the dramatic effects originally seen with corticosteroids.

Agents Targeting Tumor Necrosis Factor. Infliximab (Remicade) and etanercept (Enbrel) have actions against tumor necrosis factor (TNF), an cytokine that is important in the disease process. Both have been approved by the FDA for treating rheumatoid arthritis. They appear to have benefits for psoriasis as well. For example, in a small 2000 study, patients with psoriatic arthritis who used infliximab for 10 weeks reported dramatic improvements, and after one year, two thirds of patients had no swollen or tender joints.

Agents Targeting T-Cells. A number of important medications under investigation target helper T-cells. These are critical immune factors that researchers believe trigger the psoriasis disease process. Drugs that specifically target these molecules may be able to shut down part of the disease process without causing side effects.

Alefacept (Amevive), a drug that blocks T-cells, is showing promise in late clinical trials for achieving remission without early relapse in some patients. In one study, 34% of patients experienced improvement of about 75%, and in a 2001 trial, 24% reported complete or near complete clearance. .Others T-cell blockers under investigation and showing promise include ascomycin macrolactam (ASM-981) and hu1124.

Agents Targeting Interleukins. Interleukins are other powerful inflammatory agents of the immune system. Interleukins being investigated include IL-2 IL-8, IL-11, and IL-12. For example, daclizumab is an engineered antibody designed to block IL-2, a major stimulus for T-cell growth. Someday, it may prove to be useful in psoriasis.
Experimental Treatments
Omega-3 Fatty Acid. Fish oil has been studied because it contains omega-3 fatty acids, which help block inflammation. Taking supplements of fish oil do not appear to provide any benefits. In one 1998 study, however, omega-3 fatty acids from fish oil were administered intravenously; severity was reduced by half in 37% of these patients compared to 23% in patients receiving omega-6 fatty acids (which are contained in many plant oils).

Colchicine. Colchicine is an ancient drug long used to treat gout, and small studies are now suggesting that it is effective for treating severe psoriasis. It is particularly effective when used in solution with occlusive dressings. It is also helpful for psoriatic arthritis, although in such cases, it does not appear to improve skin lesions. A 1999 study suggests that colchicine may be effective in patients who also have renal amyloidosis, an uncommon but serious syndrome involving the kidney that is sometimes associated with psoriasis. Unfortunately, high doses of this drug are not suitable for many patients because of side effects such as nausea, vomiting, diarrhea, or abdominal cramps.

Thiazolidinediones. Thiazolidinediones are drugs that increase sensitivity to insulin and are used to treat diabetes type 2. They also affect receptors for vitamins A and D. In one study patients who took troglitazone (Rezulin) experienced significant improvement in their symptoms. (Troglitazone has been discontinued for diabetes in the US because of liver toxicity, but this study warrants further research.)  

[peterb]

General
Many medications used topically (on the skin) or orally are available for the treatment of psoriasis. Many patients require only over-the-counter treatment or even none at all during relapses. About a third of patients with psoriasis, however, do not respond to over-the-counter remedies and lifestyle changes and require aggressive treatments. In some cases, such treatments need to be life long.
 
Treatment Options
In general, the following three treatment options are used for psoriasis from least to greatest potency:
Topical Medications . Options include lotions, ointments, creams, and shampoos. These may be useful for mild-to-moderate psoriasis. Topical medicines rarely produce complete clearance, however.

Phototherapy. Options include light-wave radiation treatments using ultraviolet B (UVB) or psoralen with ultraviolet A (PUVA). This therapy is effective for moderate-to-severe psoriasis. In a 1999 study, phototherapies were much more effective than systemic drugs in achieving the longest remission. It also appears to have fewer side effects than most systemic agents. Even more promising, in a 2000 analysis comparing a number of psoriasis treatments, an advanced phototherapy called narrow band UVB achieved the highest complete clearance rate (86% of patients). (New lasers using UVB may even be more effective for certain patients.)

Systemic Agents . This treatment employs various oral drugs that affect the whole body system, not just the skin. These agents have significant side effects and are generally reserved for severe psoriasis.
Controlled comparison studies are needed to determine the safest and most effective treatments. In any case, individual requirements vary widely and treatment selection must be carefully discussed with the physician.
Treatment Sequences
Administering therapies in a specific sequence is a strategy for providing both quick relief of symptoms and long-term maintenance. It involves three main steps:

1. The quick fix is to clear the psoriatic lesions during an acute outbreak.

2. The transitional phase is intended to gradually introduce the maintenance drug.

3. On-going maintenance therapy.

Choices for transitional or maintenance regimens depend on the severity of the condition. Some examples are described in the following sections. It should be noted that combination treatments are increasingly used rather than single agents. Thousands of combinations are possible, and the patient and physician should discuss the most beneficial for individual needs.

Topical Regimen. Topical regimens are used for mild to moderate psoriasis.

An example of a topical regimen that uses a single agent is as follows:
A high-potency topical corticosteroid, such as halobetasol (Ultravate) used daily until the psoriasis plaque flattens out.

After that the steroid is applied only on the weekends for maintenance.
Another, possibly more effective, topical regimen uses the following combination for maintenance:
A high-potency steroid (halobetasol) on the weekend.

The vitamin D3 topical agent, calcipotriene, twice daily on weekdays.
In one study, over three quarters of patients with mild to moderate psoriasis remained in remission with this regimen for at least six months.

Systemic Regimens. A systemic regimen for more severe psoriasis uses the following agents:
The regimen starts with cyclosporine (known as an immunosuppressant).

Acitretin, a vitamin A derivative, is added during the transitional phase.

If the drugs are effective, the cyclosporine is withdrawn gradually after a few months and acitretin continues at as low a dose as possible.

PUVA is added if acitretin cannot control psoriasis.
Rotational Therapy
In severe chronic cases, a physician may recommend rotational therapy. This approach alternates treatments. The goal is to prevent severe side or tolerance effects from prolonged use of a single agent. An example of a rotational schedule may be the following:
Phototherapy is administered for about two years and stopped.

One or two powerful systemic drugs are then administered for one or two years and withdrawn.

Phototherapy is started again and the cycle is repeated.  

[peterb]

Phototherapy
General Recommendations for Phototherapy
Description of UVA and UVB Radiation. The two phototherapy treatments for chronic cases of psoriasis employ ultraviolet B (UVB) or ultraviolet A (UVA) radiation. Both UVA and UVB radiation are components of sunlight.

UVB is the primary cause of sunburn and primarily affects the outer skin layers.

UVA penetrates more deeply and efficiently.
When sunlight penetrates the top layers of the skin, ultraviolet radiation bombards the genetic material, the DNA, inside skin cells and injures it. It also impairs immune function in the skin. Such effects are the cause of wrinkles, aging skin, and skin cancers. These same damaging effects, however, can also destroy the skin cells that form psoriasis patches.

Although both UVA and UVB can destroy psoriasis skin cells when used in phototherapies, there are some differences:

UVB is about 1,000 times more powerful than UVA in producing sunburn. Mild pink skin (erythema) caused by UVB, in fact, can be effective against psoriasis. The same skin tone caused by UVA alone, however, does little good.

UVB may be used alone while UVA requires a photosensitizing medication to be effective. However, this combination UVA treatment, called PUVA, is generally much more potent than standard UVB therapies.

UVA poses a higher risk for skin cancers, including melanoma, than UVB.

Home use of UVB requires a physician's prescription. UVA units are available without prescription for home tanning and in tanning salons, although experts rarely recommend such treatments because of the cancer risks from over-exposure and the lack of benefit without accompanying medication.
The use of UVB and PUVA varies widely, with some centers using PUVA and others relying more on UVB. One study indicated that the use of UVA or UVB therapies tends to be based on geographic, racial, economic, and other factors rather than on conclusive evidence regarding the benefits for specific types of psoriasis. Combining phototherapy with topical or systemic agents may boost effectiveness and speed healing.

People Who Should Avoid Phototherapy. The following patients should avoid phototherapy.

People with very severe psoriasis.

Patients who are sensitive to sunlight.

Possibly people with HIV infection. One small study suggested that exposure to ultraviolet radiation may worsen HIV (which may also have implications regarding ordinary sun exposure in HIV-positive people). Antiviral therapy can help protect such patients who need phototherapy.
Broadband Ultraviolet B (UVB) Radiation
Broad spectrum UVB is radiation measured at 290 to 350 nm and has been the standard UVB phototherapy treatment. (UVB radiation below measurements of 300 nm is toxic but not effective, while radiation above 300 nm is more therapeutic.)

Broad spectrum UVB phototherapy may be administered alone. It was commonly used with coal tar (the Goeckerman regimen) in past decades and then with anthralin (the Ingram regimen). Patients dislike the use of these substances, however. Now a number of combinations of topical and oral medications are being tried. For example, combining UVB with methotrexate or retinoids, such as a tazarotene gel or oral acitretin, are showing significant results. Combinations with any other agents, however, must be supervised carefully to avoid adverse reactions.

Broadband UVB Procedures Used Without Medications. When used without medication (known as selective ultraviolet phototherapy) UVB treatment generally is administered as follows:

Treatment can be administered in the physician's office or at home with equipment obtained using a physician's prescription. Even at home, treatment must always be supervised, however.

UVB therapy usually requires about 20 to 40 treatments (about three per week).

Full results take about three weeks.

Maintenance treatment is given twice weekly for one to two months and then once a week for about four months. This is generally effective in preventing relapse.
Broadband UVB Procedures Used With Coal Tar or Anthralin. When combined with coal tar or anthralin, UVB may be administered as follows:

Treatment is administered in a psoriasis day care center. These centers are located only in certain cities, however, and treatment there may not be covered by insurance.

This combined therapy requires a full eight hours for a single treatment.

Treatments may need to be administered daily for two to four weeks.
Studies indicate that a low-dose (1%) coal tar preparation is as effective as high-dose (6%). Another study, in fact, reported that using a simple emollient (a skin softener) and administering aggressive UVB radiation until the skin turns red was as effective as using coal tar with less aggressive UVB.

Side Effects of UVB. It has not been thought that UVB treatments pose any risk for skin cancers except on male genitalia. One study reported, however, that melanoma developed in human tissue exposed to UVB radiation. Furthermore, a 1999 study suggested that UVB treatments probably cause up to two nonmelanoma skin cancers per 100 patients. Some experts postulate, on the other hand, that UVB therapy may actually have protective properties, since doses are generally low and cause the skin to thicken but not burn, a primary trigger for skin cancer.

Narrow Band Ultraviolet B (NB-UVB) Radiation
Narrow band (NB) UVB radiation uses fluorescent lighting that emits radiation in a specific range between 310 and 312 nm, which, theoretically, is the most beneficial component of sunlight. The following are some issues involved with NB-UVB:

Exposure times are shorter but of higher intensity than with broadband UVB. Burns following UVB can be more severe and longer lasting than with PUVA.

It is nearly as potent as PUVA therapy and probably is less likely to cause skin cancers. On the negative side, remission times are not as long with NB-UVB as they are with PUVA Combinations with topical agents, such as tazarotene or psoralens, may improve its effectiveness and increase remission times.

It is very efficient in reducing T-cells in the skin (the immune factors responsible for psoriasis).

The course of treatment is shorter.
One expert suggests the following NB-UVB schedule:

Treatments are performed three times a week to start.

Clearance of 75% typically occurs after 10 to 12 treatments.

Thereafter, maintenance treatments are given once a week.
Laser UVB Treatment

Treatments using a device called an excimer laser deliver a precise UVB wavelength of 308 nm. The laser targets very specific areas of skin and avoids exposing healthy skin to UV rays. This may be more effective than narrow-band UVB for localized psoriasis. Generally, four to six treatments are needed to clear psoriasis and remissions lasting for months have been achieved with six to eight treatments. One 2000 study suggested that some patients may require only one treatment to achieve moderately prolonged remission. The high UVB levels needed to clear psoriasis in a single treatment, however, can also increase the risk for skin cancer.

Psoralens and Ultraviolet A Radiation (PUVA)
PUVA treatments employ a combination of a psoralen drug and ultraviolet A (UVA) radiation. Forms of psoralen include methoxsalen, 8-methoxypsoralen (8-MOP), or bergapten (5-MOP). The effectiveness of the treatment is based on a chemical reaction in the skin between the psoralen and light, which creates redness and inflammation that prevents the psoriasis disease process.

People should avoid this treatment if they are taking drugs or have conditions that cause them to be light sensitive. They should also take protective measures before, during, and after each treatment. [See Box Protective Measures with PUVA Therapy.]

Initial PUVA Treatment Phase. The initial phase typically follows these steps:

Psoralen is usually taken orally in the form of 8-methoxypsoralen (Oxsoralen). It is administered several hours before the treatment starts. (Topical preparations of psoralen are available that can be "painted on" or applied to the affected areas by soaking or bathing in a psoralen solution. PUVA-bath therapy may be especially useful for persistent psoriasis on the palms and soles or for patients with severe nausea from the oral form.)

Psoralen reaches the skin through the bloodstream, where it increases the skin's sensitivity to UVA radiation. The amount of time a person is exposed to UVA rays depends on the skin type. Fair-skinned patients are at higher risk for redness and burning than darker skinned patients and should receive lower doses of UVA. (Some studies have suggested that reducing the standard dose of UVA by one third or one half in everyone may yield the same benefits as full dosages. If effective, such reductions would be beneficial given the long-term risks for skin cancers with PUVA.)

Treatments take about eight hours.

Inflammation and redness in the skin develop within two to three days after treatment. Such damage inhibits skin cell proliferation.

Treatments may be repeated two or three times a week. They should never be performed more frequently than once every other day, since the full effects of the treatments are not evident for 48 hours.
It takes an average of about 30 PUVA treatments for full effect, but during that period, treatment intensity may vary:

If there is no response after 10 treatments, the physician may increase the UVA energy.

If there is still no response after 15 treatments, then the psoralen dosage may be increased.

If a patient's skin does not improve at all or worsens after these changes, then the treatment is temporarily stopped. PUVA may be causing a toxic response in such cases, and, often, the condition gradually improves over the following two weeks.

If the skin does not improve, then PUVA treatment is considered to have failed. If skin improves during this resting period, then treatment resumes.
Maintenance Phase. Once the psoriasis has improved by about 95%, the patient is put on a maintenance schedule:

The patient starts with weekly treatments.

Treatment sessions gradually become less frequent until they are administered only for flare ups.

As maintenance continues and the interval between treatments lengthens, the patients may become more susceptible to tanning and sunburn. In such cases, exposure should be reduced by about 25% until the patient no longer experiences sunburn.
Success Rates. Nearly 90% of patients achieve marked improvement or clearing within 20 to 30 treatment sessions.

Combinations. Effectiveness may be enhanced or response hastened by combining PUVA with oral retinoids, such as acitretin, or drugs such as calcipotriene, methotrexate, or tazarotene gel. In addition, combinations may allow for lower doses of radiation or medications to be used, minimizing side effects. Retinoids may also help protect against skin cancers. On the other hand, methotrexate may increase the risk. In some cases, patients resistant to PUVA or UVB may respond when the phototherapies are combined.

Side Effects of PUVA. Adverse side effects include the following:

Skin reactions, including itching, sunburn, and blistering. These can generally be avoided with careful administration of PUVA therapy and protective measures. [See Box Protective Measures with PUVA Therapy.]

The psoralen methoxsalen causes malaise and nausea in 20% of patients. Dividing up the dose and taking it in 15-minute intervals with food or taking the herb ginger 20 minutes before methoxsalen is given may prevent nausea.

After treatment, white spots commonly develop where psoriasis plaques had been, particularly in people with naturally darker skin. If they are troublesome, tanning products may help darken them.

Small, dark raised spots called PUVA lentigines may also develop in affected areas with long-term treatment.
Long-Term Risks. UVA penetrates the skin more deeply than UVB, so there is a greater danger of deep skin damage and accelerated skin aging. It has been known for some time that PUVA can modify DNA and cause genetic mutations. Of concern, then, is an increased risk for cancers after PUVA treatment.

PUVA is known to increase the risk for squamous cell skin cancer and slightly increases the risk for basal cell skin cancer, both of which are nearly always curable. The risk is higher in the following patients:

Patients who have had over 200 treatments.

Patients with a family or personal history of skin cancer.

Patients with light skin and fair or red hair.

Patients who have had radiation or X-ray treatments or taken immunosuppressant drugs.
Even more worrisome was a study reporting an increased risk of melanoma, a very serious skin cancer. Discussions are under way, in fact, about discontinuing PUVA for psoriasis.

Opponents of PUVA argue that studies suggest a long-term risk for melanoma, starting about 15 years after treatment, particularly in people who receive more than 250 treatments. Although in one study only nine out of 1,380 patients developed melanoma, seven of these cases occurred in the previous five years, indicating that the danger persists and more patients in this study are likely to develop this serious skin cancer as time goes on.

Supporters of PUVA argue that it is not yet known if the people who developed melanoma experienced sunburn during the procedures or if they already had risk factors for skin cancers. If so, then properly administered treatments could still be considered safe for patients without risk factors. They also argue that PUVA is still the most effective treatment for severe psoriasis, and the alternatives are usually very powerful and relatively new drugs that may have even more serious side effects. Furthermore, the addition of retinoids may protect against skin cancers while proving to be a very effective combination.

Protective Measures with PUVA Therapy
The side effects from UVA radiation can be severe and protective measures are needed during, before, and after treatment.

Protective Measures Before Treatment. Patients should avoid prolonged exposure to the sun for 24 hours before the oral treatment starts.

Protective Measures during Treatment. During PUVA therapy, the patient should take the following precautions:
They need to wear specially designed goggles to protect the eyes from UVA radiation.

Sensitive areas, such as genitals, abdominal skin, and breasts, are covered until tanning occurs in the exposed areas, after about a third of the treatment period. (Male genitals are covered throughout the process unless they are affected by psoriasis.)
The following safety features should be available in the PUVA chamber:
Lamps with protective shields.

A viewing window so that a health professional can check the patient periodically.

A door that can be opened by the patient easily and with little pressure.

A timer that terminates the session automatically.

An accessible alarm device.
Protective Measures After Treatment. The patient should take the following precautions after treatment:
As soon as the drug has been taken and for at least 24 hours after the combined treatment, patients should wear UVA absorbing wrap-around sunglasses that are designed to completely block out stray radiation. This is important to prevent a PUVA reaction around the eyes that can cause cataracts.

For about eight hours after taking the drug, patients must also avoid exposure to daylight, even if the day is cloudy or through windows.

Patients who must go out should wear heavy opaque clothing, including hats and gloves.

Sunblocks should be applied over all exposed areas, including the lips. The sunblock should have an SPF (sun protection factor) of more than 15 and include ingredients that block UVA radiation (e.g., benzophenone, terephthalylidene dicamphor sulfonic acid, zinc or titanium oxide).

No patient should spend any prolonged time in sunlight for at least two days after the combined treatment.
 

[peterb]

WHAT ARE THE TOPICAL THERAPIES FOR PSORIASIS?
Topical medications are those applied only to the surface of the body. They come in the following forms:
Ointments.

Creams.

Sprays.

Scalp lotion.

Shampoos.

Occlusive tapes [ see Occlusive Tapes].
In general, topical treatments are the first line for mild to moderate psoriasis, but they may also be used alone or in combination with more powerful treatments for moderate to severe cases.

Topical Corticosteroids
Benefits. Corticosteroid topical treatments are commonly used because of the multiple benefits, including the following:
 
Reduce inflammation.

Inhibit cell proliferation.

Alleviate itching. (Sometimes itching can also be a side effect of the drug itself, however.)
Brands differ in potency and many are available. Some are now deliverable in foam preparations, which makes compliance much easier. They are generally given as follows:
Less potent drugs should be used for mild to moderate psoriasis.

High potency for more severe conditions.
In most cases, resistance to these drugs eventually develops or the disease recurs after treatment is stopped.

Side Effects. The more powerful a drug the more effective it is but also the higher the risk is for severe side effects. They can include the following:
Burning.

Irritation.

Dryness.

Acne.

Thinning of the skin.

Dilated blood vessels.

Loss of skin color.
 
Corticosteroids should not be used during pregnancy or when nursing. The high-potency drugs carry a small risk for adrenal insufficiency . If this occurs, the body loses its ability to produce natural steroid hormones for a period of time after the drug has been withdrawn, which can cause serious complications.

Some Topical Corticosteroids Used for Psoriasis.
 
Low potency   Hydrocortisone (Hytone, Penecort, Synacort, Cort-Dome, Nutracort).

Desondide (Tridesilon).

Flumethasone pivalate (Locorten).

Fluocinolone acetonide (Synalar, Derma-Smoothe).  
Low to medium potency  Alclometasone dipropionate (Aclovate). Hydrocortisone (Locoid, Pandel).

Desonide (Tridesilon).

Hydrocortisone valerate (Westcort)
 
Medium potency  

Clocortolone pivalate (Cloderm).

Fluticasone propionate (Cutivate). A low-dose ointment (0.005%) is proving to be effective for psoriasis on the face and in folds of the skin, but not in other areas.
 
High potency  

Halobetasol propionate (Ultravate).

Clobetasol propionate (Temovate).

Betamethasone (Diprolene). (Available as a foam for the scalp. In one 1999 study, 72% of patients were clear or almost clear of disease after 28 days of treatment, compared with 47% who were clear after using the lotion.)

Diflorasone diacetate (Florone, Maxiflor, Psorcon).

Mometasone furoate (Elocon). (Only needs to be administered once a day. May be as or more effective than corticosteroids at the same strength while having a lower risk for severe side effects.)  

Tar
Tar preparations have been used for psoriasis for about 100 years. Crude coal tar inhibits enzymes that contribute to psoriasis and helps prevent cell proliferation. Tar is often used in combinations with other drugs and with ultraviolet B (UVB) phototherapy. [ See What Are Phototherapy Treatments for Psoriasis?, below.]

Side Effects. Preparations have the following drawbacks:
The drug can cause sun sensitivity and increase the risk for sunburn for up to 24 hours after use.

It has a strong smell.

It can stain clothing.

It irritates the skin.

Ingesting the medication is life-threatening. In such cases poison control should be called immediately.
Anthralin
Benefits. Like coal tar, anthralin (Dritho-Scalp, Drithocreme, Micanol), called dithranol in Europe, is a traditional medication, in use since the early 1900s. It appears to benefit patients with psoriasis by slowing skin cell reproduction. Remissions can last for months. Anthralin is recommended only for chronic or inactive psoriasis, not for acute or inflamed eruptions.

Forms. The most effective form is a hard paste, which patients find difficult to use compared to ointment and cream preparations. (Anthralin, however, offers fewer benefits in the easier-to-apply forms.) Alternatives being investigated are the following:
An encapsulated form (Micanol) may prove to be effective while being less irritating and cause less staining than the hard paste.

A 1% anthralin ointment has been tried in a method called short-contact therapy. It is applied for only one-half hour to two hours, after which the medication is removed and the area washed thoroughly.
Application. In all cases anthralin should be applied carefully. The following are some suggestions for application:
Because anthralin can irritate normal skin, it should not be used on the face.

After the paste is applied, affected areas are powdered with talcum and wrapped in a dressing to protect surrounding areas.

Hands should be washed thoroughly after use.

Anthralin can stain hair, fabrics, plastics, and other household products. Sinks or tubs or any other product used during the application should be rinsed with hot water immediately and then followed by the use of a cleanser.
To apply anthralin to the scalp, the following is recommended:
The psoriatic areas should be soaked first in warm mineral oil.

The hair is combed to remove any scaly debris.

It is then parted to expose the areas of plaque.

The anthralin solution is applied only to the patches and rubbed well.

Patients should be sure that the medication does not spread to the forehead or exposed areas.
Side Effects
Skin irritation and burning. It should not be used on the face. Fair skinned people should generally avoid it.

Brown staining.

Although topical preparations do not appear to affect areas other than the skin, people with kidney problems are advised to use anthralin with caution.
Topical Vitamin D3 Analogs
A topical form of vitamin D3, calcipotriene (Dovonex), called calcipotriol in Europe, is proving to be both safe and effective.

Benefits. Calcipotriene has the following benefits:
It appears to help block skin cell proliferation.

It enhances the maturity of keratinocytes (the impaired skin cell in psoriasis).

It has anti-inflammatory properties.
It is at least as effective as the potent topical corticosteroids, short contact anthralin, and coal tar in improving mild to moderate plaque psoriasis. Improvement occurs between two and six weeks and most cases of psoriasis clear by 14 to 36 weeks after treatment. Compliance is very good. It is now available in a foam preparation, which makes compliance even easier. Several other vitamin D3 analogs, such as maxacalcitol and talcalcitol, are also showing promise.

Side Effects. They include the following:
Calcipotriene causes skin irritation in about 20% of patients and so should not be used on the face. In fact, it causes greater skin irritation than potent corticosteroids. This rarely causes a patient to stop using the drug.

Although the drug appears to be safe and effective in children, there is some concern that it may lower levels of vitamin D to the extent that they affect bone growth. More studies are needed to determine this effect.
Topical Retinoids
Retinoids are vitamin A derivatives and are being used for various skin disorders. Tazarotene (Tazorac, Zorac) is the first topical retinoid found to be effective for mild to moderate psoriasis.

Benefits. Tazarotene gel benefits the targeted skin tissue without causing the adverse systemic effects of oral retinoids. One study reported that improvements occurred within a week of treatment, and depending on the potency, the drug was successful in 59% to 70% of patients. It can irritate the skin, but overall it is very safe. It should be noted, however, that when used alone it is less effective than many other treatments. Combinations, such as with topical steroids or phototherapy are more effective.

Tacrolimus

Tacrolimus (Protopic) is a topical agent that suppresses immune factors. It may help clear psoriasis lesions without the adverse effects that corticosteroids have. Initial results are promising and further study is underway. Although approved for eczema, the ointment is not yet indicated for psoriasis so it is not covered by most insurers.

Occlusive Tapes
Watertight (occlusive) tapes may help heal psoriasis and are particularly useful for psoriatic cuts on the palms and soles. (In such cases, the tape should be applied across the cuts until they heal.) Occlusive tapes retain sweat, which helps restore moisture to the outer skin layer and prevent scaling. They also protect against abrasion and irritation.

High-Potency Corticosteroid Tapes. Applying a corticosteroid beneath an occlusive tape or using one already impregnated with a potent corticosteroid (Cordran Tape), such as flurandrenolide, may be especially beneficial. Studies are showing that high-potency corticosteroid-impregnated tapes are more effective than using high-potency corticosteroid ointments alone. The downsides are the following:
The corticosteroid-impregnated tape is expensive.

It produces a higher incidence of skin irritation than the ointment alone.

It produces more pronounced rebound effects than the ointment (a relapse of symptoms after stopping treatment).

Steroid-impregnated tapes increase the risk for secondary infections, which may be prevented by changing the tapes every 12 hours.

The use of corticosteroids under occlusive materials on large areas of psoriasis increases the risk for adrenal insufficiency, a sometimes dangerous condition that occurs because the body loses its ability to produce natural steroids. Children are especially susceptible.
Fluorouracil with Occlusive Tapes. One study applied a cream containing fluorouracil underneath an occlusive tape. The dressing was applied two or three times a week for an average of about 16 weeks and resulted in 90% clearing in 11 out of 15 patients. Improvement persisted beyond three months in five patients.  
 

[Alison]

wow what a read

   intresting one at that.

the only 1 out of that lot thats really helped me is the puva , i dunno what il do tho when my nxt out break comes along , cant have puva 4 ever can you ,

some of the oral drugs have pretty sacrey side effects dont they

[peterb]

No PUVA has limits.  I found this short piece

"Because of earlier research showing an association between PUVA and nonmelanoma cancers,9 current medical practice limits the lifetime number of sessions to 250".

[Alison]

No PUVA has limits.  I found this short piece

"Because of earlier research showing an association between PUVA and nonmelanoma cancers,9 current medical practice limits the lifetime number of sessions to 250".

o i should be alright for quite some time then , ive had about 32 sessions for my hands n 22 for my feet.

they do make you sign befor each course tho that you accept theres a risk of skin cancer

[janstew]

the only thing i didnt see mentioned is advantan which is prednisone cream. maybe its an ozzie thing!!! the strongest steroid i have yet in a cream

jan