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Psoriasis
By Paula Begoun |
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I remember seeing advertisements in magazines when I
was about 12 or 13 with predominant headlines that read
"Do you suffer the heartbreak of psoriasis?" At the time
I suffered from persistent acne and severe eczema which
continually broke my heart, but I had no idea why something
called psoriasis should be so devastating. Shortly after
that a girlfriend of mine confided in me that she had
psoriasis. Although it didn't impact her face (which is
why I didn't know), it covered almost her entire body
which she always kept well covered with clothing. Hesitantly,
she lifted her pant legs and shirt to show me. I finally
understood the heartbreak. She went from doctor to doctor
seeking relief and spent a lot of time on vacation in
sunny locales, but inevitably, she struggled with the
discomfort and embarrassment. What was truly a heartbreak
back then is that there were limited, relatively ineffective
options for treating psoriasis. Today there have been
amazing medical breakthroughs and there is new hope for
those with this persistent skin problem.
Psoriasis is a chronic recurring skin disease, identified
by the presence of thickened scaly areas and papules (small,
solid, often-inflamed bumps that, unlike pimples, do not
contain pus or sebum). These bumps are usually slightly
elevated above the skin surface, sharply distinguishable
from normal skin, and often red to reddish brown in color.
They are usually covered with small whitish/silver scales
that stick to the cyst-like swelling and, if scraped off,
may bleed or ooze. For some, psoriasis may be nothing
more than a few small, scaly patches at the hairline or
on the sides of the nose, for others the disease can cover
the entire body. Most typically, the elbows, knees, scalp,
and chest are afflicted. Psoriasis affects more than 7
million people in the United States alone, but for most
people it tends to be mild and unsightly rather than a
serious health concern, which is probably why fewer than
2 million people seek medical treatment for it (Source:
OTC Journal Newsletter, October 15, 2001, online
at http://www.otcjournal.com/profiles/astr/20011015-1.html).
No one knows for certain exactly what causes psoriasis
and there is no cure, although the latest studies strongly
suggest it may be related to an immune system problem,
which triggers inflammation. Research has shown that psoriasis
is triggered by the activation of T-cells (a type of white
blood cell). These cells affect the immune system and
release cytokines (chemical messengers that stimulate
the production of other substances, both positive and
negative). In psoriasis patients, these cytokines send
faulty messages causing skin cells to reproduce and mature
at an enhanced rate. This miscommunication leads to the
visible lesions and scaling in psoriasis. A normal skin
cell matures in 28 to 45 days, while a psoriatic skin
cell takes only 3 to 6 days. Both men and women can get
psoriasis at any age, but most often it strikes persons
in their 20s and 30s. Still, it isn't unusual to start
noticing red, swollen, flaky bumps on your skin late in
life. It is also believed that psoriasis is genetic: one
third of patients have family members who also suffer
from this unsightly skin condition (Sources: PCI Journal,
Volume 12, Number 5, 2004; The Journal of Immunology
Online, January 2005, pages 164-173; and Dermatology
Online Journal, February 2003, page 2).
Several forms of psoriasis can occur with the most common
being plaque psoriasis characterized by small, often-inflamed
bumps that resemble blemishes but do not contain pus or
sebum. Other forms include guttate psoriasis, typified
by small dotlike lesions all over the body; pustular psoriasis,
with weeping lesions and intense scaling; and erythrodermic
psoriasis, marked by severe sloughing and inflammation
of the skin. Psoriasis can range from mild to moderate
to severe and disabling. On occasion, some people who
have psoriasis experience spontaneous remissions, but
no one knows why or when that may happen.
Sadly, there is still no cure for psoriasis, but there
are many different treatments, both topical and systemic,
that can clear it for periods of time. Experimenting with
a variety of options is essential to find the treatment
that works for you, but all require a doctor’s attention
and, most importantly, patient compliance.
Battle Plans for Psoriasis
Of the various therapies available to treat psoriasis, it
is generally best to start with those that have the least-serious
side effects, such as topical steroids (cortisone creams);
topical vitamin D preparations, retinoids, salicylic acid,
coal-tar creams, lotions, cleansers, or shampoos; prescription
topical medicines, and careful exposure to sunshine. If
those methods are not successful, you can proceed to the
more serious treatments involving oral medications. More
often than not, successful treatment requires a combination
of methods.
Topical Treatments
Phototherapy/Sunlight: This may sound contradictory
to my usual and unyielding warnings about avoiding prolonged
and unprotected sun exposure, but extended periods of time
in the sun (also referred to as "climatotherapy") can significantly
improve, or even clear, psoriasis. In fact some research
indicates that 60% of those using this kind of treatment
can obtain relief for a period of time (Source: Clinical
Experimental Dermatology, July 2004, pages 413-414 and
Israel Medical Association Journal, February 2003,
pages 87-88). ultraviolet (UV) light from the sun suppresses
the skin’s immune response and, therefore, reduces that
type of inflammation, resulting in a slowed overproduction
of skin cells that cause scaling. Daily, short, nonburning
exposure to sunlight clears or improves psoriasis in many
people. Therefore, sunlight may be included among initial
treatments for the disease (Source: National Institutes
of Health, Department of Health and Human Services, Questions
and Answers about Psoriasis, January 2002, online at
http://www.niams.nih.gov/hi/topics/psoriasis/psoriafs.htm).
Of course, this convenient, inexpensive treatment has serious,
profound drawbacks including advanced skin aging, far greater
risk of skin cancer, and impaired immune response. Given
the wide range of options for treating psoriasis that do
not involve sun exposure, it is not as uniformly recommended
as it once was (Source: Toxicology and Applied Pharmacology,
March 2004, pages 298-308).
UVB lamps: When real sunlight isn't available, an
alternative to natural sunlight exposure is medically supervised
administration of narrow-band ultraviolet B (UVB) lamps.
UVB light is also used when topical treatments have failed,
or in combination with topical treatments. The short-term
risks of using controlled narrow-band UVB exposure to treat
psoriasis is minimal, and long-term studies of large numbers
of patients treated with narrow-band UVB have not demonstrated
an increased risk of skin cancer, suggesting that this treatment
may be far safer than sunlight (Source: Photodermatology,
Photoimmunology, and Photomedicine, August 2003, pages
164-168). It is understood that narrow-band UVB lamps are
safer because they do not emit UVA light and control the
range of UVB impact. Sunlight has both ultraviolet A (UVA)
and UVB radiation and it is believed that UVA is far more
dangerous than UVB. A great deal of research points to UVA
as the main cause for skin cancer and skin aging (Source:
Skin Pharmacology and Applied Skin Physiology, September-0ctober
2002, pages 316-320). Narrow-band UVB treatments are considered
one of the most efficacious and cost-effective therapies
for moderate to severe psoriasis, with the least amount
of risk. This type of therapy is generally effective for
2/3 of psoriasis patients (Source: www.psoriasis.org/treatment/psoriasis/uvb.php).
It is important to point out that tanning beds or sun beds
found in salons or spas are mostly fitted with UVA bulbs
that emit minimal UVB emissions. Unfortunately, these are
widely used by patients with psoriasis even though they
are minimally effective (Source: British Journal of Dermatology,
November 2002, pages 966-972).
UVB emitting lasers: A relatively new treatment for
psoriasis is the use of lasers that emit narrow-band UVB
light. It can clear skin lesions faster than direct sunlight
or UVB lamps, and 70% of those receiving this treatment
can be almost completely free of lesions after 10 treatments
(Sources: British Journal of Dermatology, December
2003, pages 1250-1258; and Journal of Cosmetic Laser
Therapy, June 2003, pages 101-106).
These lasers work in a manner similar to controlled UVB
phototherapy (described above), in that a specific wavelength
of light is directed toward the lesions. The light is believed
to initiate the death of T-cells, rendering them unable
to trigger the immune system to signal rapid cell proliferation.
The most well-known laser for psoriasis is the 308nm (nanometer)
excimer laser. It emits a single wavelength, and unlike
UVB treatment, the excimer laser can be focused solely on
psoriatic lesions, thus sparing the surrounding healthy
skin from radiation. As a result, this laser can be used
at a strength that is six times more potent than UVB radiation.
The result? Better clearance of psoriasis lesions with fewer
treatments, typically 4-10 sessions compared to 25-30 for
UVB treatments (Sources: Cosmetic Dermatology, September
2004, pages 559-560; British Journal of Dermatology,
December 2003, pages 1250-1258; and www.laserskinsurgery.com).
Lasers: Other types of lasers such as ablative (meaning
injurious) options such as the CO2 and Erbium: YAG lasers
have been used to treat psoriasis, but the results have
been mixed. Pulsed dye lasers have had a successful treatment
history, with 585nm being the most common wavelength used.
The light emitted by this device targets the blood vessels
contributing to the formation of lesions. Extended clearance
of lesions is a common outcome for many psoriasis patients
undergoing PDL treatments, though not all lesions respond
the same. In other words, you may get great results on your
arm or elbow, but less satisfactory outcome for facial lesions.
This inconsistency is attributed to the underlying (dermal)
blood pattern affecting each lesion. In general, larger
and redder lesions respond less favorably than lighter ones
(Source: Archives of Dermatology, volume 133, 1997,
pages 921-922). Despite this news, the excimer laser is
still believed to be the best choice for successful treatment
of psoriasis lesions (Source: Der Hautarzt, March
2003, pages 242-247).
Coal tar: Treating psoriasis with coal tar is a very
old treatment option. It is a topical medication available
both over the counter and by prescription; the difference
is in the potency and amount of coal tar the medication
contains ranges from 1% to 5% creams and ointments. Coal
tar inhibits the substances in skin that incite rapid cell
proliferation, thus reducing the appearance and severity
of psoriasis. Coal tar can be combined with other psoriasis
medications (like topical steroids) or with sunshine (UV).
However, coal tar can make the skin more sensitive to UV
light, and extreme caution is advised when you combine coal
tar use with UV therapy (or exposure to the sun) to avoid
getting a severe burn or causing skin damage. Other downsides
to coal tar are the irritation it can cause, the smell,
and its tendency to stain clothes (Source: www.niams.nih.gov/hi/topics/psoriasis/psoriafs.htm#5).
These cosmetically inelegant aspects are what prevent many
psoriasis patients from adhering to a regimen of coal tar
treatments. However, because of new, more effective topical
treatments, particularly vitamin D analogues, coal tar is
not prescribed as often as it once was. (Sources: Journal
of Dermatologic Treatment, January 2004, pages 14-22;
International Journal of Dermatology, October 2003,
pages 834-838; Clinical and Experimental Dermatology,
March 2002, pages 99-103; American Journal of Clinical
Dermatology, February 2001, pages 95-120; and The
Skin Sourcebook, Alan S. Boyd, M.D., 1998, page 263.)
Anthralin or dithranol: Similar to coal tar, anthralin
(also called dithranol) is a topical prescription medication
that has been used to treat psoriasis for decades. It works
best in cases of mild to moderate psoriasis. Although anthralin's
action on skin is not clear, it appears to inhibit cell
proliferation and can be very effective in treating psoriasis.
It is often used in combination with other treatments. It
has few serious side effects but can cause extreme irritation
or burn the normal-appearing skin surrounding psoriatic
lesions. Anthralin also stains anything it comes into contact
with. It is prescribed in a range of concentrations, but
the most effective form is a hard paste that is very difficult
to apply, requiring a great deal of patience; also, it can't
be used over inflamed lesions, and must not get on the face.
There are a variety of regimens for its use, but the negative
side effects and cumbersome and time-consuming application
process often make it a less-than-desirable option. (Sources:
Skin Pharmacology and Applied Skin Physiology; January-February
2003 and November-December 2002, pages 50-58; Experimental
Dermatology, February 2004, pages 78-85; and British
Journal of Dermatology, April 2003, pages 779-783.)
Vitamin D Analogues: A range of studies have demonstrated
an impressive improvement in psoriatic lesions with the
topical application of calcipotriene (trade name Dovonex),
a derivative of vitamin D3, when used alone or in combination
with other therapies (Sources: British Journal of Dermatology,
June 2004, pages 1167-1173; and American Journal of Clinical
Dermatology, February 2001, pages 95–120). By the way,
this calcipotriene is not the same compound as the vitamin
D found in commercial vitamin supplements or added to food
products such as milk or cereal.
Calcipotriene acts not only to inhibit cell proliferation
and enhance cell differentiation in the skin of patients
with psoriasis, but also appears to affect the substances
in skin that generate the increased growth of localized
cells. In several well-designed, short-term studies in adults,
the efficacy of calcipotriene ointment (50 micrograms twice
daily) was similar or superior to the efficacy of several
other antipsoriatic agents in adult patients with mild to
moderate psoriasis. Calcipotriene is generally well tolerated
in short- and long-term studies in adult patients, with
the major side effect being irritation. In addition, calcipotriene
ointment proved benefits in combination with other topical,
phototherapy, or systemic antipsoriatic treatments, including
reducing the dosage and/or duration of some of these treatments
and potentially improving their benefit to risk ratio. A
recent study involving 972 psoriasis patients showed that
calcipotriol (another name for calcipotriene) combined with
betamethasone dipropionate (a corticosteroid) ointment provided
more effective clearance of psoriasis lesions over a twelve
week period than calcipotriene alone. All told, calcipotriene
ointment is valuable as a first- or second-line therapy
option alone or in combination with other antipsoriatic
agents for severe psoriasis. Other forms of vitamin D3 creams
include calcitriol and tacalitol. (Sources: Journal of
Dermatologic Treatment, April 2004, pages 98-103; Current
Drug Targets—Inflammation and Allergy, June 2004, pages
199-204; and Journal of the American Academy of Dermatology,
March 2004, pages 416-430.)
Topical corticosteroids: Cortisone creams have been
used for years as the first-step approach in the treatment
of psoriasis, and are available in a wide variety of textures
(from ointments to gels) and concentrations. Cortisones
reduce inflammation, itching, and potentially slow skin
cell proliferation. They are often used successfully with
other treatments as well. However, the more powerful the
corticosteroid, the higher the risk of more severe side
effects, which include burning, irritation, dryness, acne,
thinning of the skin, dilated blood vessels, and loss of
skin color. Less potent topical steroids are often used
for mild to moderate psoriasis, saving the high-potency
versions for more severe conditions. An effective regimen
uses high-potency cortisones, such as halobetasol (Ultravate),
daily until the psoriasis plaque flattens out, after which
the medication is applied only on the weekends. Another
high-potency corticosteroid, mometasone (Elocon), needs
to be administered only once a day and is as effective,
or more effective than other corticosteroids while having
a lower risk of severe side effects. These very potent drugs
carry a small risk of causing hormonal problems for a period
of time after the drug has been withdrawn. The larger the
area treated with corticosteroids, the higher the risk,
especially if the area is covered by heavy material or is
bandaged. Also, in most cases, resistance to these drugs
eventually develops (Sources: Journal of the American
Academy of Dermatology, November 2004, pages 811-813;
American Journal of Clinical Dermatology, May 2004,
pages 71-77; Journal of Dermatologic Treatment, January
2003, pages 8-13; and http://my.webmd.com/content/article/1680.51881.)
Topical retinoids: such as Tazorac (active ingredient
tazarotene) have been shown to have a positive effect on
plaque psoriasis particularly in combination with other
treatments (Sources: International Journal of Dermatology,
January 2001, pages 64–66; and Cutis, January 1999,
pages 41–48). The manner in which it works is similar to
potent topical steroids but with the advantage of a longer
periods of relief during treatment and no detrimental side
effects or damage to skin (Source: Expert Opinion on
Pharmacotherapy, April 2003, pages 2347-2354). In addition,
combining tazarotene with topical steroids not only provides
better treatment but also reduces the skin-thinning side
effects of corticosteroid use (Source: Skin Pharmacology
and Physiology, May-June 2004, pages 111-118). Tazarotene
is also available as an oral prescription, though studies
comparing systemic to topical application of this drug are
lacking. As with other retinoids, tazarotene is not recommended
for use while pregnant.
Salicylic acid: Often called beta hydroxy acid, salicylic
acid is sold over the counter in strengths of 1.8% to 3%,
but prescription strengths of 6% are often recommended in
the treatment of psoriasis. Because it is a keratolytic
(exfoliant), it can soften and remove scaly skin layers
of psoriatic lesions. Removing these built-up skin layers
is important because it allows other topical medications
to better penetrate skin. Also, because of salicylic acid's
chemical relationship to aspirin, it has anti-inflammatory
properties and can reduce the redness associated with psoriasis.
Salicylic acid is available in many forms, and it is often
combined with other topical medications to enhance their
effectiveness in the treatment of psoriasis (Source: http://www.psoriasis.org).
(Sources: Archives of Dermatology, January 2005,
pages 43-46; and Journal of Cutaneous Medicine Surgery,
May-June 2002, pages 12-16.)
Systemic Treatments
Methotrexate: Anti-cancer drugs have recently begun
to play a part in the treatment of psoriasis, and Methotrexate
is one such medication. It is an immune-modulating drug
known for its ability to reduce the uncontrolled overproduction
of cells. It is an established and highly effective systemic
treatment for severe psoriasis and has been widely used
during the last three decades. Methotrexate works by binding
to an enzyme involved in the quickened growth of cells,
and also slows down the growth of skin cells that leads
to psoriasis. Thankfully, the long-term adverse effects
of methotrexate are well known. The most frequent adverse
effects that occur during methotrexate therapy are abnormal
liver function test results, nausea, and gastric complaints.
The most feared adverse effects are liver damage and the
suppression of bone marrow activity. However, liver problems
associated with methotrexate are related to a high cumulative
dose. This means that rotating types of therapy or using
methotrexate intermittently instead of continuously can
reduce the risk. Most people tolerate low-dose methotrexate
therapy relatively well, provided they work closely with
their physician and watch carefully for adverse effects
and drug interactions during treatment. The long-term clinical
efficacy and relative safety of methotrexate remain impressive.
(Sources: Journal of Dermatology, October 2004, pages
798-801; Journal of Cutaneous Medicine and Surgery,
December 2004, pages 1-2; British Journal of Dermatology,
July 2004, pages 3-15; Annals of the Rheumatic Diseases,
November 4, 2004; and American Journal of Clinical Dermatology,
January-February 2000, pages 27–39).
Methotrexate is not recommended for women who are or plan
to become pregnant.
Cyclosporin (trade name Neoral): A strong immune-suppressant
drug, cyclosporin is a primary medication used to prevent
the rejection of transplanted organs such as liver, kidneys,
and heart. In skin diseases, cyclosporin acts by reducing
inflammation in the skin and reducing cell proliferation
by blocking immune factors (T-cell lymphocytes) that are
likely generating the problem. It was FDA-approved for psoriasis
in 1997, with the proviso that it not be used for more than
a year at a time. Studies have shown cyclosporin to be highly
effective and well tolerated in short-term treatment of
severe psoriasis, including on the nails (Sources: American
Journal of Clinical Dermatology, 2001, volume 2, issue
1, pages 41–47; and Journal of Cutaneous Medicine and
Surgery, Volume, April 2004, pages122-125). However,
this is a serious medication. Temporary side effects of
cyclosporin can include headaches, gingivitis, joint pain,
gout, body-hair growth, tremors, high blood pressure, kidney
problems, and fatigue. Of serious concern is the National
Toxicology Program's Eighth Report on Carcinogens,
1998, which warns that cyclosporin is "known to be a human
carcinogen based on studies in humans." All of these factors
must be weighed and carefully assessed before deciding on
this course of treatment. Generally, cyclosporin therapy
is reserved for use when other treatments have failed.
Acitretin (Soriatane), and isotretinoin (Accutane)
are oral retinoids. Acitretin is similar to isotretinoin,
except that acitretin is the only retinoid approved by the
FDA for use in the treatment of psoriasis. Isotretinoin
is approved by the FDA for use in treating acne. How retinoids
work in the treatment of psoriasis is not completely understood,
although they are thought to block the overproduction of
skin cells.
Neither of these retinoids are to be used when a woman is
pregnant because all systemic retinoids have strong potential
to cause major fetal abnormalities, including neurological
and skeletal deformities. It is essential that effective
contraception be used for at least one month before and
throughout treatment. Severe fetal abnormalities do occur
if a woman is or becomes pregnant while taking either acitretin
or isotretinoin (Accutane), but because Accutane doesn't
remain in the system for long after you are finished with
treatment, an extended waiting period is not required before
becoming pregnant. Specifics regarding how long to wait
after treatment before considering having a baby should
be discussed with your physician. In contrast, acitretin
can remain in the body up to three years following
treatment. Therefore, it is imperative that pregnancy not
occur during this time. If you are planning to conceive,
discuss the pros and cons of acitretin versus isotretinoin
with your physician (Sources: Dermatologic Clinics,
October 2004, pages 467-47; and Journal of the American
Academy of Dermatology, March 2004, pages 416-430).
Important note: Women of childbearing age should
not consume alcohol during and for two months following
treatment with acitretin. Alcohol can cause this drug to
convert to a form that may remain in the body indefinitely.
Other side effects associated with oral tretinoin therapy
include dry skin and lips, and, to a lesser extent, liver
damage and, potentially, depression.
Etanercept (trade name Enbrel): An interesting addition
in the treatment of psoriasis is the antitumor medication
Etancercept that is used in the treatment of rheumatoid
arthritis. Etanercept also appears to be a promising agent
that can be used in combination therapy for the treatment
of psoriasis (Sources: American Journal of Clinical Dermatology,
volume 6, issue 1, 2005, pages 49-59; and British Journal
of Dermatology, January 2002, pages 118–121). Six months
of treatment (consisting of one or two injections per week)
typically lead to a significant improvement in psoriasis
symptoms (Source: PCI Journal, Volume 12, Number
5, 2004, page 24). It is generally well-tolerated, with
the most common side effect being a reaction at the injection
site.
5-fluorouracil (brand name Efudex): Chemotherapy
agents such as 5-fluorouracil may be effective in the treatment
of psoriasis affecting the nails. Psoriatic-affected nails
are quite common for those with psoriasis—up to 50% of those
with psoriasis have it in their nails, too. There is no
consistently effective treatment for psoriasis of the nail,
though there are a handful of studies showing a topically
applied 5% 5-fluorouracil cream can be beneficial (Sources:
Cutis, July 1998, pages 27–28; and Clinical and
Experimental Dermatology, Volume 25, Issue 5, September
2000, page 357).
Infliximab (trade name Remicade): Used to treat Crohn's
disease and rheumatoid arthritis, Infliximab also is used
for those with some forms of psoriasis, though it is not
yet FDA-approved for the latter (trials are currently underway
to attain FDA approval). It is an injectible drug composed
of antibodies derived from mice and humans. Results are
often seen within 2 weeks, with lesion improvement considered
excellent (Sources: International Journal of Immunopathology
and Pharmacology, September-December 2004, pages 373-380;
Cosmetic Dermatology, November 2002, page 33; and
www.fda.gov/cder/foi/label/2002/inflcen062802LB.pdf). Adverse
effects include reactions at the site of injection (in clinical
trials, 19% of subjects had such a reaction), fever, chest
pain, chills, hypo- and hypertension, and shortness of breath.
The most serious side effects are reactivation of tuberculosis
in patients who have had this illness and the potential
development of lymphomas. Although a clear causative factor
has not been established, the theory is that immunosuppressive
drugs such as Infliximab "provide a biologic basis for concern
and justification for the initiation of additional epidemiological
studies to formally evaluate this possible association."
(Source: Cosmetic Dermatology, September 2004, pages
563-564). This medication clearly has strong potential to
quickly alleviate the symptoms of psoriasis, but its side
effects should be carefully discussed with your physician.
Alefacept (trade name Amevive): One of the first
biologic drugs approved by the FDA specifically to treat
moderate to severe plaque psoriasis is Alefacept. It works
by reducing the number of immune-activated T-cells in the
skin, thus significantly reducing the major cause of psoriasis.
It is administered by your physician via once a week injections
for a period of 12 weeks. After this, the treatments are
suspended in order to observe changes in the skin. If results
are positive (meaning symptoms regress) further treatment
is not needed until symptoms return and remissions of up
to seven months are not uncommon. Because Alefacept suppresses
the immune system in order to relieve psoriasis symptoms,
side effects include an increased risk of infection or other
potentially serious problems including an increased risk
of cancer. Therefore, your physician must monitor your progress
while on this medication, a process that includes weekly
blood tests, usually done at or shortly after the time of
each injection. The purpose of this is to make certain that
T-cells and other immune system cells are not suppressed
to the point that your general health is compromised (Sources:
www.niams.nih.gov/hi/topics/psoriasis/psoriafs.htm#5; and
PCI Journal, Volume 12, Number 5, 2004).
Efalizumab: Similar to Alefacept, Efalizumab is FDA-approved
for the treatment of psoriasis. It works by preventing the
migration of immune-activated T-cells from the lymph nodes
into the skin. By doing so, the inflammatory response that
leads to symptoms of psoriasis is kept in check. It is important
to note that while this drug blocks T-cell migration to
skin, it does not reduce the number of T-cells in the body.
Unlike alefacept, efalizumab can be self-injected in the
comfort of your own home. It should be administered on a
weekly basis. After three to six months of treatment, the
majority of psoriasis patients experience significant reduction
of symptoms. Results last up to three months in greater
than 50% of patients, and this drug is typically well-tolerated.
In contrast to Alefacept, Efalizumab does not cause immunosupression,
though the period of remission does not last as long as
what can take place with Alefacept. In clinical trials,
it was noted that some patients experienced an immediate
flaring up of symptoms once the medication was stopped (Sources:
Cosmetic Dermatology, September 2004, page 566; and
PCI Journal, Volume 12, Number 5, 2004, page 24).
Combination Therapy
PUVA: The most typical combination therapy for psoriasis
is something called PUVA. PUVA is an abbreviation combining
a prescription medication called Psoralen and exposure to
ultraviolet light A (UVA). It is also called "photochemotherapy."
The drug Psoralen, which can be taken orally as a pill or
applied topically to the skin, makes the skin more sensitive
and receptive to the wavelength of UVA light (320 to 400
nanometers). This combination suppresses the growth of abnormal
skin cells. The good news is that PUVA can eliminate or
dramatically reduce psoriatic lesions for the majority of
people who use it, and there is evidence it can provide
extended remissions. The bad news is that Psoralen and UVA
light are phototoxic and carcinogenic. Getting rid of psoriasis
can mean a lot, but putting your skin at risk for premature
aging and cancer may be trading one problem for another.
PUVA therapy brings with it an increased risk for squamous
cell carcinoma among those who have fair skin and endure
more than 200 treatments (not an unheard of number given
that even with treatment psoriasis is a chronic skin disorder).
Despite large scale international studies, evidence about
whether or not PUVA therapy increases the risk of malignant
melanoma (the most serious form of skin cancer) is conflicting
(Sources: Cosmetic Dermatology, May 2004, page 5;
and International Journal of Dermatology, August
2004, pages 555-561).
In light of the risks involved, PUVA should be considered
only for extreme or disabling psoriasis, after other treatments
have failed (Sources: http://www.psoriasis.org; Cutis,
November 2001, pages 345–347; and Biochemical Pharmacology,
January 2002, pages 31–39). Although the risks to skin are
considerable, it should be noted that compared to UVB phototherapy,
PUVA treatments were shown (via a 100-person randomized
study) to clear psoriasis symptoms in a greater number of
patients and with fewer treatments (16 PUVA treatments vs.
25 UVB treatments). Further, six months after treatment,
35% of patients treated with PUVA were still in remission
compared to just 12% of UVB-treated psoriasis patients (Source:
Cosmetic Dermatology, Volume 17, Issue 5, May 2004,
page 4).
All of the above treatments, both topical and oral, are
often used in varying combinations for the best results.
Frequently, several combination treatments are used in rotation
to reduce the potentially harmful side effects of each one.
Discovering whether any of these will work for you, alone
or in combination, takes patience and a systematic, ongoing
review and evaluation of how your skin and health are doing.
Successful treatment, as is true with all chronic skin disorders,
requires diligent adherence to the regimen and a realistic
understanding of what you can and can’t expect. It is also
important to be aware of the consequences of the varying
treatment levels. For example, continued long-term use of
topical cortisone creams can cause skin thinning, stretch
marks, and built-up resistance to the cortisone medication
itself, so that it actually becomes an ineffective treatment.
Exposure to sunlight without adequate protection (particularly
from UVA radiation) can cause skin cancer. Oral steroids
can have serious withdrawal effects, including increased
bouts of psoriasis. Accutane and acitretin cause birth defects
if a woman becomes pregnant while taking them. Several systemic
psoriatic treatments can cause liver problems, nausea, and
severe irritation. Each option has its own set of pros and
cons that need to be researched and discussed at length
with your physician.
For more information on the current status of available
treatments, visit the Web site for the National Psoriasis
Foundation (NPF) at http://www.psoriasis.org/.
Shopping for Skin-Care Products While
Battling Psoriasis
It won't come as a surprise to anyone dealing with psoriasis
that over-the-counter or "traditional" skin-care products
are incapable of curing or minimizing outbreaks. Still,
if you have psoriasis, you may be wondering if there are
any pointers to follow while shopping for skin-care products.
Yes, there are. However, rather than psoriasis-specific
guidelines, these directives fall under the category of
general skin care so that you don't use products that can
exacerbate the problem. All the basic skin-care needs are
important for those with psoriasis, with an even stricter
adherence to only using products free of fragrance and unnecessary
irritants. Treating your skin to a routine of gentle cleansing,
sun protection (discussed with your physician), and using
a moisturizer loaded with antioxidants and anti-inflammatories
will keep psoriasis lesions from looking or feeling worse
and allow them to respond better to topical and systemic
treatments. As long as everything you use is gentle, you
will want to select products based on your skin type—oily,
dry, or combination.
The only skin-care exception for those with psoriasis is
avoiding the use of topical scrubs over psoriasis-affected
areas of skin. As discussed above, salicylic acid (BHA)
is an option to control some of the symptoms of psoriasis.
However, topical scrubs can be too abrasive and potentially
irritating to use over psoriatic skin. Using AHA products
is an option, but because these acids are not oil-soluble,
they are not considered as effective as BHA for treating
psoriasis lesions. Because my product line is fragrance
and irritant-free, I feel comfortable recommending it as
an option for those with psoriasis. For Paula's Choice skin-care
options, click
here.
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