RISK FACTORS: Local trauma; local irritation, Infection (streptococcal pharyngitis can stimulate acute guttate psoriasis, HIV), Endocrine changes, Stress (physical and emotional),
Sudden withdrawal of systemic and/or potent topical steroids
GENERAL MEASURES
β’ Solar radiation
β’ Mild disease: ultraviolet radiation (UVA/UVB)
β’ Medication to soften scale, followed by soft brush while bathing
β’ Oatmeal baths for itching
β’ Tar shampoos
β’ Avoid excessive sun exposure
β’ Desert climates may provide a favorable effect
β’ Wet dressings may help relieve pruritus
β’ For extensive, recalcitrant psoriasis, a referral to a specialist in psoriatic therapy is suggested
ACTIVITY No restrictions
DIET No special diet
PATIENT EDUCATION
β’ Provide patient reassurance and anxiety relief to the extent possible
β’ Assurance to patient and family the condition is noncontagious
DRUG(S) OF CHOICE
. Mild to moderate disease:
. Emollients bid: soft yellow paraffi n or aqueous cream; petrolatum or Aquaphor cream greasier and more effective
. Topical, low potency corticosteroids on delicate skin (eg, face, genitals or fl exures). Alclometasone
dipropionate, triamcinolone acetonide 0.025%, hydrocortisone 2.5%
. Topical, medium potency corticosteroids (fluticasone propionate, triamcinolone acetonide 0.1%, hydrocortisone valerate, mometasone furoate usually for lesions on the torso) tid-qid (overnight occlusion with plastic wrap will hasten resolution). Switching products prevents tachyphylaxis. Non-fluorinated is less atrophogenic.
. Topical, strong potency corticosteroids - betamethasone dipropionate, halcinonide, fluocinonide,
desoximetasone
. Topical, super potency corticosteroids - augmented betamethasone dipropionate, diflorasone diacetate, clobetasol propionate, halobetasol propionate. Limit use to 2 weeks if possible, avoid occlusive dressings. Taper to prevent rebound. Usually reserved for recalcitrant plaques or lesions on palms or soles of feet.
. Intralesional corticosteroid: 2-5 mg/mL triamcinolone acetonide
. Coal tar (Estar, PsoriGel) may be beneficial when alternated with topical steroids. Apply and air dry for 15 minutes before going to bed or apply in AM for 15 minutes, then shower. Tar bath preparations for widespread involvement.
. Keratolytic agents to decrease scale: salicylic acid 6% gel (or 2-10% salicylate acid ointment) bid several weeks. Even 20% for 2 weeks, except in children. alpha hydroxy acid, glycolic acid or lactic acid. Alternate keratolytics with other topicals.
. Corticosteroid solutions, betamethasone valerate mousse and tar shampoos - scalp lesions
. Ultraviolet lamps and sun light effective. May be best treatment option during pregnancy or in young children.
. UVB + emollients in erythemogenic dose in fair skinned patients - less toxic than PUVA
. Anthralin ointment 1% or higher applied for 5-30 minutes, then washed off, useful adjunctive treatment. Use prior to ultraviolet light (UVA, UVB). Indicated for quiescent or chronic psoriasis, contraindicated in acute or actively inflamed psoriatic eruptions. Start with 0.1%, gradually increase to 3.5%. Irritates unaffected skin, protect areas with zinc oxide or petrolatum. Avoid face, eyes, mucous membranes.
New preparation - Micanol delivers drug at body temperature so staining household items minimized.
. Severe disease:
. Triamcinolone, intralesional - mix with procaine or normal saline for concentrate of 4 mg/mL. Administer with syringe or dermajet. Effective in treating solitary resistant plaques and psoriasis involving the nails.
. Vitamin D analogs (calcipotriene ointment 0.005% for moderate plaque psoriasis). Results may not be
maximal for 2 months. Too irritating for facial lesions. Watch for hypercalcemia if large quantity used. Weekly cumulative dose < 100-120 gram. Associated with little or no tachyphylaxis. Calcipotriene is inactivated by salicylic acid, ammonium lactate lotion and hydrocortisone valerate 0.2% ointment. Halobetasol proprionate 0.05% and 5% tar gel are compatible.
. Acitretin (Soriatane) - oral retinoid (active metabolite of etretinate) replaces etretinate (Tegison) which had
120 day half life. Safe for use on face. Also treats pustular and erythrodermic psoriasis not responding to standard treatment. Fetotoxic. Contraception needed one month before, during and for at least 3 years after treatment. Ethanol may convert acitretin to etretinate so no ethanol while using acitretin. Women should refrain from drinking alcohol for 2 months after treatment stopped.
. Tazarotene (Tazorac) - for psoriasis involving up to 20% body surface area. Avoid face and groin due to
irritation. Daily or every other day treatment. Retinoid induced dermatitis major side effect.
. Oral corticosteroids only for severe or life-threatening disease (risk of rebound)
. Isotretinoin: may work on some patients
. PUVA oral (psoralen plus ultraviolet light) - very effective, but causes skin-aging, cataracts and increases risk of skin cancers
. Bath PUVA - topical psoralen applied 5 min to 2 hours before UVA. Better for soles, palms, ie, localized disease, because less nausea of systemic psoralens. May cause severe local phototoxic reaction and patchy pigmentation.
. Goeckerman regimen - black tar/UVB all day treatment.
Psoriasis Day Treatment Programs.
. Methotrexate - single weekly dose (up to 25 mg) or 2.5-5 mg q12h for 3-4 days per week, but precautions
necessary. Hydroxyurea for methotrexate failure. Azathioprine and intralesional cyclosporine, not common.
. Cyclosporine or tacrolimus [S/E of paresthesias, diarrhea]: only for recalcitrant psoriasis (possible
nephrotoxicity)
- Cyclosporine: regimens for short-term use only, perhaps alternating with other agents. Gradual taper over 12 weeks when stopping minimizes relapse.
ALTERNATIVE DRUGS
. RePUVA (acitretin plus PUVA)
. Mycophenolate mofetil (CellCept) 250-500 mg qid for recalcitrant disease (hematologic and hepatic toxicity,
teratogenic; check CBC weekly during fi rst month, twice monthly second and third month, then monthly;
contraception needed)
. Thioguanine - anti-metabolite. Risk of myelosuppression. Check CBC and platelets q 2 wks, and q wk with
dose increase
. Narrow band UV-B therapy (311-nm)
. Combined systemic treatments - MTX or hydroxyurea + PUVA, acitretin or MTX, or calcipotriene + UVB
. Sequential therapy
. Clearance phase - 1 month class 1 topical steroid every AM, calcipotriene qhs + cyclosporine 4-5 Mg/kg/day
. Transition phase - 1 month calcipotriene bid weekdays, class 1 topical steroids bid weekend and gradually acitretin
. Maintenance phase - until remission; calcipotriene bid then taper; continue acitretin; taper and stop
cyclosporine
PATIENT MONITORING
β’ Continuous supportive care
β’ Medications used require close followup. Certain lab studies necessary. Long-term use of topicals not
recommended.
β’ With methotrexate therapy check CBC, SGOT, albumin every month. Some recommend liver biopsy before
treating or 3 months after treatment started and then regularly (usually every 2 years) based on a cumulative
methotrexate dose of 1.5 grams.
PREVENTION/AVOIDANCE
β’ Avoid alcoholic beverages
β’ Avoid irritating drugs
β’ Avoid stimulating drugs (lithium, ACE inhibitors, betaadrenergic blockers, tetracycline, NSAIDs, amiodarone,
morphine, procaine, potassium iodide, salicylates, sulfapyridine, sulfonamides and penicillin. Pustular flares may occur with steroids).
β’ Avoid antimalarial medications (aminoquinolone compounds)
POSSIBLE COMPLICATIONS
β’ Pustular psoriasis
β’ Exfoliative erythrodermatitis
β’ Rebound when corticosteroids discontinued
β’ Topical corticosteroid thinning of skin, striae, masking local infection, hypopigmentation and tachyphylaxis
β’ Hypercalcemia with excessive calcipotriene
β’ Salicylism possible in children with high dose topical salicylic acid.
EXPECTED COURSE/PROGNOSIS
β’ Usually benign
β’ Life-threatening forms do occur
β’ May be refractory to treatment