Treating Psoriasis Vulgaris - There are Lots of Options

By L. Guenther, MD, FRCPC

Psoriasis vulgaris, the most common form of psoriasis, is an autoimmune disease. Approximately 1/3 of patients with psoriasis have a relative with psoriasis, and 85% have a link with the HLA-Cw6 gene. Learn more on Psoriasis Guide .CA

Diagnosing Psoriasis:

The following may be signs that you have psoriasis:

• Red, scaly plaques that are often itchy and are commonly located on the elbows, knees, lower backl area, and scalp, although any part of the skin may be affected
• Chronic, but may have periods of remission
• May have associated nail changes (pitting, lifting up of the nails and detachment from the nail bed, nail plate thickening and other changes)
• May have psoriatic arthritis which includes sore joints (in ~30% of population). (See PsoriaticArthritisGuide.ca for more information)

Psoriasis has a great mental and physical impact on people's lives as many find it embarrassing, and unattractive. This can lead to depression and suicide.

Treatment: Self-Help and Medical Treatments:

Treatment depends on:

• the sites of involvement
• severity
• response to previous treatment
• other medical conditions
• concomitant medications
• proximity to medical resources (e.g., phototherapy units)
• patient preference

Avoid Aggravating Medications

In some patients some blood pressure and heart medications (e.g. beta-blockers, ACE inhibitors), antimalarials and lithium may aggravate the disease or make it more resistant to treatment.

Topical Agents

These are the most commonly used treatments, either as monotherapy for localized disease, or as adjunctive treatment for moderate-to-severe disease.

Topical Corticosteroids

• Available in low, medium, high and ultra high potency
• Use lotions for the scalp, creams and ointments elsewhere, and gels anywhere
• Use the steroid with the lowest effective potency, particularly on the face and folds
• Safe for short-term or intermittent long-term treatment
• Examples include: hydrocortisone, betamethasone

Vitamin D derivatives

• Topical calcipotriol (Dovonex®)- available in a cream or ointment for trunk and limbs; also a solution for the scalp ),
• Topical Dovobet® which contains calcipotriol and betamethasone dipropionate (a topical corticosteroid) It has greater efficacy than its individual components.

Vitamin A derivatives

Topical Tazarotene (Tazorac® - a selective retinoid) available in a cream and gel

Topical Calcineurin Inhibitors

• Topical pimecrolimus (Elidel®‚ 1% cream) and tacrolimus (Protopic®‚ 0.03% and 0.1% ointment) twice daily for facial and intertriginous psoriasis

Intralesional Corticosteroids

• Small plaques may be injected with triamcinolone 10mg/cc diluted with saline or water

Treating Moderate-to-Severe Psoriasis:

Psoriasis is considered to be moderate-to-severe if it

• affects10% or more of the body surface area, OR
• less than 10% if:
      - a) Plaques are very red, thick, and scaly, or
      - b) There is a significant impact on quality of life (Read about Quality of Life and Psoriasis on http://www.psoriasisguide.ca/medical_treatment/quality_of_life.html )
      - c) Disease is resistant to topical treatment.

Treatment of Moderate-to-Severe Psoriasis is usually one of the following in combination with topical treatment:

1. Phototherapy with ultraviolet B or PUVA [psoralen (a photosensitizer) + ultraviolet A ]
2. Traditional systemic agents (i.e. Methotrexate, Cyclosporine, Acitretin )
3. Biologic agents (i.e. Alefacept (Amevive®), Efalizumab (Raptiva®) or Etanercept (Enbrel®))

If you have psoriasis or suspect that you do, it is important to see a physician to get appropriate treatment options for your specific condition and situation.

About the Author:
Dr. Lyn Guenther is a Professor in the Division of Dermatology at the University of Western Ontario, Medical Director of The Guenther Dermatology Research Centre, past president of the Canadian Society for Dermatologic Surgery and Medical Editor of Dermatology Times of Canada. She sits on a number of national and international committees. She has been involved in clinical research since 1980, has lectured internationally and has authored numerous publications. Read her complete profile on dermatologists.ca/d_60.html