Goals of Treatment

Aim of the treatment (short-term/long-term)

• Reduce the itching, especially of the scalp, and control or reduce skin shedding.
• Identify and remove triggering factors that are known to aggravate psoriasis, such as infection, stress and trauma. Control of obesity and cessation of smoking are critical targets in the management of psoriasis.1,2
• 1. Setty AR, et al. Smoking and the risk of psoriasis in women: Nurses' Health Study II. Am J Med. 2007 Nov;120(11):953-9.
• 2. Johnston A, et al. Obesity in psoriasis: leptin and resistin as mediators of cutaneous inflammation. Br J Dermatol. 2008 Aug;159(2):342-50.
• Improve patient quality of life.

What happens if no treatment is sought?

If there is only minimal body surface area (BSA) involvement, i.e., patches are limited to the elbows or knees, apart from redness and scaling, many patients elect to either do little or avoid seeking any treatment whatsoever.

When there is 3-5% BSA involvement, treatment is generally sought because the presence of scaling plaques are deemed to be unattractive and control of the uncomfortable itching often necessitate medical attention.

Recently published reports emphasize that patients with severe psoriasis are at 50% increased risk of death as compared with people who do not have the skin condition. There was no overall effect of mild psoriasis on mortality. [Gelfand JM, et al. The risk of mortality in patients with psoriasis: results from a population-based study. Arch Dermatol. 2007 Dec;143(12):1493-9] Determinations on whether specific anti-psoriatic therapies will reduce the risk remains to be seen. Consequently, at-risk patients should be screened for co-existing conditions, such as cardiovascular disease and metabolic syndrome, in order to decrease their risk of mortality.

Does treatment affect quality of life?

Although psoriasis cannot be cured, the wide spectrum of available treatment options enables dermatologists to substantially improve the quality of life of affected patients. With the advent of biologic agents, patients with severe psoriasis or those that are resistant to conventional therapies, have expanded therapeutic options. Many of these patients who were previously faced with limited treatment options and incapacitated by their psoriasis, respond to biologics and have been able to return to a relatively normal life.

Describe areas of uncertainty

Apart from not knowing the cause of psoriasis, patients with this skin condition are faced with therapeutic choices that expose them to significant side-effects:

Methotrexate: long-tem use is associated with an increased risk for hepatic, hematologic and oncologic adverse events.

PUVA: patients are exposed to photodamage and photo-irradiation, which can increase their susceptibility for developing skin cancers.

Biologics: these agents include tumor necrosis factor (TNF) blockers, which have been shown to carry a risk of serious adverse effects and at present, long-term data is lacking to accurately define the risk. After being advised of the increased risk of death in patients with severe psoriasis, as compared to non-psoriatic patients, we are not aware of any systemic therapies that will alter the outcome.