Mild Psoriasis: Topical SteroidsTo review current understandings of and approaches to topical psoriasis therapies and to assess their efficacies and adverse effects. Other studies were included where level I research was unavailable. No level III research was included. Psoriasis is very topical steroid treatment for psoriasis and causes substantial morbidity. Because most psoriasis is mild to moderate, patients are well suited to outpatient topical therapy. Advances in topical treatments for psoriasis have kept pace with a rapidly evolving comprehension of its pathogenesis, making a review of current therapies useful for those who treat psoriasis.
Topical Psoriasis Therapy - American Family Physician
Mar 27, Author: Adjuncts to treatment include sunshine, moisturizers, and salicylic acid as a scale-removing agent. Treatments for more advanced psoriasis include narrowband ultraviolet B UVB light, psoralen with ultraviolet A UVA light retinoids eg, isotretinoin [Accutane, Claravis], acitretin [Soriatane] , methotrexate particularly for arthritis , cyclosporine Neoral, Sandimmune , infliximab Remicade , etanercept Enbrel , adalimumab Humira , apremilast Otezla , and secukinumab Cosentyx.
Decreased effectiveness of infliximab or adalimumab in a patient previously well controlled on the medication may mean that antibodies to the medication are being produced. In a study of ustekinumab in patients with moderate-to-severe psoriasis, investigators did not observe an increased trend in dose-related or cumulative toxicity with the duration of ustekinumab treatment.
The investigators also reported rates of adverse events generally comparable to those of other biologics approved for managing moderate-to-severe psoriasis. It has been suggested that 91 kg pounds might be a better cutoff for the higher dose for optimal control. Recommendations from a international consensus report on treatment optimization and transitioning for moderate-to-severe plaque psoriasis include methotrexate and cyclosporine, biologic agents, and combination therapy.
The AAD guidelines recommend treatment with methotrexate, cyclosporine, and acitretin, with consideration of the contraindications and drug interactions noted in the discussion of each medication below.
Many other medications are used off label for psoriasis. Many of these are drugs approved initially for rheumatoid arthritis or inflammatory bowel disease but are found to also have benefits in skin psoriasis. Tofacitinib citrate, a Janus kinase inhibitor, is such a medication that has shown promise in the treatment of psoriasis.
Topical corticosteroids are the mainstay of treatment for mild and limited psoriasis. They can reduce plaque formation. These agents have anti-inflammatory effects and may cause profound and varied metabolic activities.
The strength of topical steroid and vehicle are chosen according to the thickness of plaques and body location. No topical corticosteroids are conclusively superior in efficacy or adverse effects than others in the same class.
Some formulations such as foams and solutions are easier to use in the scalp than either creams or ointments. A patient who has been doing well on a topical steroid who begins to have worsening, especially with itching, should be evaluated for either a concomitant fungal infection or the development of allergic contact dermatitis to a steroid or vehicle component.
Potent and superpotent corticosteroids generally only need be applied once daily unless the scale on a plaque is particularly thick. Extended use of very potent steroids should be avoided when possible in the treatment of genital and inverse psoriasis. Triamcinolone treats inflammatory dermatosis responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
It has mild potency and is the first drug of choice for most patients. Betamethasone treats inflammatory dermatosis responsive to steroids. It is a potent topical steroid and is the drug of choice if psoriasis is resistant to milder forms. Ophthalmic corticosteroids treat conjunctival, corneal, and anterior chamber inflammation. These agents help control infiltration and delay vascularization. Care must be taken with long-term use because of concerns about infection with viruses such as herpes simplex or fungal infections.
Prednisolone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely. Dexamethasone is used for various allergic and inflammatory diseases. It decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Coal tar is an inexpensive treatment that is available over the counter in shampoos, lotions, creams, or foam for use in widespread areas of involvement. It is particularly useful in hair-bearing areas.
Tar preparations may be especially useful when combined with topical corticosteroids. This may be accomplished by applying the products sequentially or, when available, obtaining them from a compounding pharmacy.
Treatment with tar preparations may be especially useful when combined with topical corticosteroids. Coal tar is antipruritic and antibacterial and inhibits deregulated epidermal proliferation and dermal infiltration. It does not injure the normal skin when applied widely, and it enhances the usefulness of phototherapy. It generally is used as a second-line drug therapy due to messy application, except for shampoos, which may be used and rinsed at once.
Removing the thick scale allows topical corticosteroids and other topical medications to better reach the target tissues and achieve better results. This is especially important on the scalp. Many over-the-counter preparations can be used for this, most of which contain salicylic acid. Lactic acid, ammonium lactate, and urea are other ingredients that may be applied before or at the same time as other topical medications.
Anthralin reduces the rate of cell proliferation. Its chemically reducing properties may also upset the oxidative metabolic processes, further reducing epidermal mitosis. It is not the first or second drug of choice due to irritation problems of normal skin surrounding lesions and staining of the skin. Vitamin D analogs are used in patients with lesions resistant to topical therapy or with lesions on the face or exposed areas where thinning of the skin would pose cosmetic problems.
These come as ointments, solutions, and foams. Calcitriol is a topical vitamin D analog similar to calcipotriene but seems to be less irritating in sensitive areas of skin. Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. It is used in the treatment of moderate plaque psoriasis. This treatment does not cause long-term skin thinning or systemic effects. Sorilux is a newer foam version of this medication.
It inhibits epidermal proliferation, promotes keratinocyte differentiation, and has immunosuppressive effects on lymphoid cells. Betamethasone is a corticosteroid that decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
The combination product is quite expensive and the same results may be obtained by using a generic corticosteroid sequentially in combination with one of the other vitamin D analog products.
Aqueous gel formulations are odorless and colorless, and no long-term skin damage has been noted with topical retinoids. There is also no threat of worsening if the therapy is withdrawn, as with steroids. These drugs should not be used in women if pregnancy is a possibility. Tazarotene is a retinoid prodrug that is converted to its active form in the body and modulates differentiation and proliferation of epithelial tissue and perhaps has anti-inflammatory and immunomodulatory activities.
It may be the drug of choice for those with facial lesions who are not at risk of pregnancy. Tazarotene, although topical, is a category X medication. Topical tretinoin is of less use in psoriatic patients. A strategy that may be tried in patients who experience unacceptable irritation is to use short contact times. There are several protocols, but the least irritating is to apply the medication for min and then wash off.
The total time on may be increased by minutes every few weeks until clinical efficacy or adverse cutaneous effects are seen. This short-contact method may be especially useful when one is using it in skin folds but is less effective for the plaque with very thick scale.
Methotrexate inhibits dihydrofolic acid reductase. Dihydrofolates must be reduced to tetrahydrofolates by this enzyme before they can be utilized as carriers of one-carbon groups in the synthesis of nucleotides and thymidylate. Subsequently, methotrexate interferes with DNA synthesis, repair, and cellular replication. Actively proliferating tissues are in general more sensitive to this effect of methotrexate. Topical tacrolimus has been used in the past for management of refractory atopic dermatitis.
However, multiple studies have shown effectiveness with psoriasis affecting intertriginous regions as well as the face. Generally, it seems to be effective in thin-skinned areas. However, it has become somewhat of a second-line agent given other studies showing topical steroids may be more effective and potential serious disease association. Cyclosporine is an amino acid cyclic peptide and natural product of fungi.
It acts on T-cell replication and activity. Cyclosporine is a specific modulator of T-cell function and an agent that depresses cell-mediated immune responses by inhibiting helper T-cell function. Preferential and reversible inhibition of T lymphocytes in the G0 or G1 phase of cell cycle is suggested. The drug binds to cyclophilin, an intracellular protein, which, in turn, prevents formation of interleukin IL -2 and the subsequent recruitment of activated T cells. It specifically inhibits T-lymphocyte function with minimal activity against B cells.
Maximum suppression of T-lymphocyte proliferation requires that the drug be present during first 24 h of antigenic exposure. Cyclosporine suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions eg, delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft versus host disease for a variety of organs. Remission is usually rapid with this therapy; however, skin lesions tend to recur within days to weeks after treatment is stopped although patients do not usually have the severe rebound that patients withdrawing from therapy may have.
For adalimumab, weight-based dosing regimens exist for pediatric-aged patients. For etanercept, some patients will require twice-weekly dosing of the induction period indefinitely in order to maintain satisfactory control. It is also indicated to reduce signs and symptoms, and to improve physical function of patients with psoriatic arthritis. It is indicated for adults and children aged 4 years and older with moderate-to-severe psoriasis. It is used to treat moderate-to-severe psoriasis and moderate-to-severe psoriatic arthritis.
The mechanisms by which phosphodiesterase-4 PED4 inhibitors elicit anti-inflammatory effects are not completely understood. Unlike biologics that neutralize inflammatory mediators at the protein level, apremilast modulates mediator production at the level of mRNA expression. It may affect cytokines and chemokine synthesis, leading to anti-inflammatory effects.
It is indicated for moderate-to-severe plaque psoriasis in adults who are candidates for phototherapy or systemic therapy. Secukinumab is a human IgG1 monoclonal antibody that selectively binds to and neutralizes the proinflammatory cytokine ILA.
ILA is a naturally occurring cytokine that is involved in normal inflammatory and immune responses and plays a key role in the pathogenesis of plaque psoriasis. Following the initial once-weekly SC dosage regimen, the drug is given as a maintenance dose once monthly.