Health Tips

Topic 3: Treatment of Psoriasis

Welcome to DOC2US Psoriasis Health Tips Section. Hope you liked our previous articles and let’s continue our discussion on psoriasis today.

“I am diagnosed with psoriasis. How will my condition be managed?”

There are many effective treatments readily available in the pharmacy to help patients achieve the next best thing to a cure: clear or almost clear skin and reduced inflammation.^1,2 Depending on the severity of your condition, your physician will determine the best treatment for you.

It's natural in today's world for us to want to learn more about the condition we're in. You may have come across terms like 'topical therapies' or 'systemic therapies' while researching psoriasis and wondered what they meant.

In general, topical therapies for psoriasis are creams or ointments applied only to the affected area of the skin, whereas systemic therapies are either oral medications or injections.³ Ointments are typically thicker and greasier, but they are the most effective for those with extremely dry skin, whereas creams are less greasier and easier to apply than ointments.⁴

Continue reading to learn more about psoriasis treatment options!

Emollients, also known as medical moisturizers, are essential in the treatment of psoriasis.^1,4

Regardless of your condition’s severity and the therapy you are on, emollients should be used regularly if you have psoriasis.¹ The British Dermatological Nursing Group recommends that a moisturizer should be applied and allowed to sink in before using another treatment.⁴ This often takes around 30 minutes.⁴ 

Choose products containing either ceramides or shea butter to repair the skin’s moisture barrier and avoid those with fragrance and sulfate as they can further irritate the skin.⁵

By maintaining optimum skin hydration, moisturizers can reduce the itchiness, dryness, cracking and scaling associated with psoriasis and may aid in the absorption of active ingredients of other topical therapies, which can improve the skin response to the treatment.⁴

If your condition is in the mild-moderate category, your physicians or dermatologists will usually opt for topical therapies, such as creams or ointments.¹

Image credit to Pharmaceutical Online

Corticosteroids creams or ointments are one of the first therapies your physician or pharmacist will recommend to you if your psoriasis only covers a small surface of your body.⁶

Corticosteroids are often used in reducing inflammation and irritation for patients with psoriasis.^2,6 Most patients report a rapid reduction in inflammation after applying topical corticosteroids.² There are many strengths available from mild to very strong formulations. Burning, stinging, thinning of the skin and hair growth are some of the potential side effects, but these effects usually disappear after treatment has finished, or can be controlled by using a lower strength of steroid.⁶ It is important to consult your physician or pharmacist and use the right strengths for the right condition and body area to reduce the risks of any side effects. For sensitive areas such as face, body folds and private parts, opt for a milder preparations.^1,6

Another common therapy will be salicylic acid creams or ointments, normally given alone, or in combination with corticosteroids creams or ointments for mild-moderate psoriasis.¹ Salicylic acid may dry out your skin and lead to skin peeling and irritation, but the peeling effect is intended to soften and rejuvenate the scaly skin, helping to remove the bothersome scales associated with psoriasis.^2,7,8 The dryness can be managed easily by moisturizing, applying sunscreen regularly and limiting sun exposure.⁷ Remember not to apply it on the wounds, eyes and mouth area.⁷

Vitamin D analogues gels or ointments such as calcipotriol or calcitriol are another therapy commonly given to help slow down the skin cells production and reduce inflammation in psoriasis.⁹ One thing to note is that vitamin D analogues make your skin more sensitive to the sun.⁹ Hence, remember to apply your sunscreen regularly.9 Apart from potential skin irritation, topical calcipotriene usually have minimal side effects and the risk of hypercalcemia is low if the medication is used the right way.² Do note that vitamin D analogues are not the same as vitamin D supplements and they cannot be replaced by one another.⁹

Coal tar creams or ointments are other forms of therapies that have been used to treat mild-moderate psoriasis for many years, especially scalp psoriasis.¹⁰ Coal tar is effective in reducing inflammation and scaling.^2,10 However, it does have an unpleasant odour and it can be pretty messy, staining one’s skin, clothing and hair.^2,10 As it may irritate the skin, it should not be applied to the wounds, eyes and private areas.¹⁰

Calcineurin inhibitor creams or ointments such as tacrolimus and pimecrolimus are effective for face and flexures psoriasis.¹ One thing to note is that they increase the skin’s sensitivity to the sun.¹¹ Hence, apply sunscreen regularly and avoid tight-fitting medical dressings while you are on it.¹¹

When will my symptoms improve?
With proper adherence to topical therapies, the improvements can be expected as early as one week. However, some might take a few weeks to see the improvement of symptoms.²

Phototherapy or oral therapies are options if you fall in the moderate-severe category for psoriasis. You may be required to perform some laboratory tests before commencing these medications.¹

Image credit to Medical News Today

Phototherapy is recommended for patients with moderate to severe chronic plaque psoriasis.¹ If >5% of your body surface area is affected, you may also opt for phototherapy performed by a dermatologist.^2,12 This is because it might not be practical to apply topical therapies to such a large area.² It is divided into Psoralen (P) and ultraviolet A (UVA) (PUVA) therapy and narrowband UVB therapy.¹² One thing to note is that phototherapy may lead to skin damage, premature ageing and increase the risk of skin cancer.¹²

Oral therapies, such as cyclosporine, methotrexate and acitretin are recommended for people with moderate to severe psoriasis who do not respond to or are unsuitable for, topical therapies or phototherapy.^13,14

Image credit to Medical News Today

Both cyclosporine and methotrexate reduce inflammation and the formation of thick scaly plaques.^13,14 They are both efficacious in treating moderate-severe plaque psoriasis.¹ 

Avoid drinking grapefruit juice or eating grapefruit while taking cyclosporine as studies have shown that it might increase cyclosporine levels in the blood.¹³ Besides, you should always take the same brand as the absorption of cyclosporine may vary from brand to brand.¹³ Cyclosporine may be given as a short-term treatment such as 12 to 16 weeks as it may lead to renal toxicity in cumulative doses.^2,15 Blood pressure, renal function and lipid profile should be monitored closely by the doctor while on this medication.^2,13

Methotrexate is commonly used for moderate to severe plaque psoriasis.¹⁴ It leads to a more rapid and cost-effective clearance of patients with severe psoriasis compared to cyclosporine at doses with comparable safety profile.¹⁶ Practice contraception and avoid pregnancy for at least 3 months after taking methotrexate due to its high risk of spontaneous miscarriage.^1,2 Your physician will usually prescribe folate supplementation for you while you are on this medication to prevent certain side effects.² One of the concerns regarding long-term methotrexate use is its impact on the liver and kidney.^2,14 But don’t worry as your physician will schedule you for regular blood tests to monitor your condition.¹⁴

You should inform your physician right away if you detect any signs or symptoms of an infection as you might be more susceptible to infections while on cyclosporine and methotrexate.^13,14

Acitretin reduces the formation of thick scaly plaques.¹⁷ Acitretin should be avoided in women of childbearing age without reliable contraception and in those who are planning for pregnancy.¹ Apply sunscreen regularly and reduce exposure to the sun as it may make the skin more sensitive to sunlight.¹⁷ Some other potential side effects include dry mouth and eyes, burning sensation on the skin, eye inflammation, nausea and vomiting, headache and bleeding gums.¹⁷

Biologics (e.g. adalimumab, guselkumab, secukinumab, ustekinumab etc.) are important treatments for people with severe plaque psoriasis, who do not respond to phototherapy and systemic therapies.¹⁸

Image credit to CDMO

Studies have shown that biologics have a good safety profile and can be used for short and long-term treatment. Biologics are generally well-tolerated by patients with psoriasis.¹⁹ Biologics target the root cause of psoriasis, resulting in fewer and less severe side effects compared to non-biologic oral therapies.²⁰ Although they can be quite expensive, biologics are also usually more effective than non-biologic oral therapies.¹⁹ You will be screened for active infections before starting the medication.¹⁸ One thing to note is that biologics may cause infections such as upper respiratory tract infections and fungal infections.¹⁸ They are also associated with other side effects such as inflammation at the injection sites and headache.¹⁸

Friendly reminder…

With the right treatment, you can see significant improvement in your skin appearance and the symptoms over time as these treatments help to keep the condition under control. Regardless of the treatment, do follow-up regularly with your dermatologist for the best outcome.²

Where can I refer to for more information?

You can always refer to the resources below:

     ●   MOH CPG on Management of Psoriasis Vulgaris
          MANAGEMENT OF PSORIASIS VULGARIS

     ●   DermNet NZ on Guidelines for the management of psoriasis
          Guidelines for the management of psoriasis | DermNet NZ

     ●   Psoriasis Association on Treatment of Psoriasis
          Treatments for Psoriasis

Have you read our previous article: Diagnosis of Psoriasis? Click here to know more https://www.doc2us.com/topic-2-diagnosis-of-psoriasis.

Learn more about psoriasis in the next topic in this series – Biologics for Psoriasis.

CP-321119 JULY 2022

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REFERENCES

1. MOH Clinical Practice Guidelines. Management of Psoriasis Vulgaris (June 2013). Available at https://www.moh.gov.my/moh/attachments/9004.pdf. Website Accessed: 26th January 2022
2. Feldman, S.R. (2022). Treatment of psoriasis in adults - UpToDate, Available on https://www.uptodate.com/contents/treatment-of-psoriasis-in-adults?search=psoriasis&sourc e=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7 Website Accessed: 26th January 2022
3. Spriggs. B. B. (2019). Topical, Injectable, and Oral Medication for Plaque Psoriasis: What You Need to Know. Retrieved from https://www.healthline.com/health/psoriasis/injectable-vs-oral-meds Website Accessed: 29th of April 2022
4. Psoriasis Association. (2018). Moisturisers and Emollients. Available on https://www.psoriasis-association.org.uk/moisturisers-and-emollients Website Accessed: 24th March 2022
5. Cobb, C. (2020). 7 Things to Avoid Putting on Your Skin with Psoriasis - Healthline. Available on https://www.healthline.com/health/psoriasis/what-not-to-put-on-your-skin-with-psoriasis Website Accessed: 26th January 2022
6. Psoriasis Association. (2017). Topical Steroids. Available at https://www.psoriasis-association.org.uk/topical-steroids Website Accessed: 24th March 2022
7. MIMS Malaysia. Salicylic acid. Available on https://www.mims.com/malaysia/drug/info/salicylic%20acid?mtype=generic Website Accessed: 26th January 2022
8. Arif, T. (2015). Salicylic acid as a peeling agent: A comprehensive review. Clinical, Cosmetic and Investigational Dermatology, 8, 455-461. doi: 10.2147/CCID.S84765 Website Accessed: 29th of April 2022
9. Psoriasis Association. (2017). Vitamin D Based Topicals. Available at https://www.psoriasis-association.org.uk/vitamin-d-based-topicals Website Accessed: 24th March 2022
10. Psoriasis Association. (2021). Coal Tar. Available at https://www.psoriasis-association.org.uk/coal-tar Website Accessed: 24th March 2022
11. MIMS Malaysia. Pimecrolimus. Available on https://www.mims.com/malaysia/drug/info/pimecrolimus?mtype=generic Website Accessed: 26th January 2022
12. Psoriasis Association. (2018). Ultraviolet Light Therapy. Available at https://www.psoriasis-association.org.uk/uv-light-therapy Website Accessed: 24th of March 2022
13. Psoriasis Association. (2017). Ciclosporin. Available at https://www.psoriasis-association.org.uk/ciclosporin Website Accessed: 24th March 2022
14. Psoriasis Association. (2017). Methotrexate. Available at https://www.psoriasis-association.org.uk/methotrexate Website Accessed: 24th March 2022
15. American Academy of Dermatology Association (AAD). (2022). Psoriasis Treatment: Cyclosporine. Retrieved from
    https://www.aad.org/public/diseases/psoriasis/treatment/medications/cyclosporine#:~:text=The%20preferred%20way%20to%20take,that%20last%20about%2014%20weeks. Website Accessed: 8th of June 2022
16. Sandhu, K., Kaur, I., Kumar, B., & Saraswat, A. (2003). Efficacy and safety of cyclosporine versus methotrexate in severe psoriasis: a study from north India. The Journal of dermatology, 30(6), 458–463. https://doi.org/10.1111/j.1346-8138.2003.tb00416.x
17. Psoriasis Association. (2017). Acitretin. Available at https://www.psoriasis-association.org.uk/acitretin Website Accessed: 24th March 2022
18. Psoriasis Association. (2021). Tremfya (Guselkumab). Available at https://www.psoriasis-association.org.uk/tremfya Website Accessed: 24th March 2022
19. Ngan, V. (2022). Guidelines for the management of psoriasis - DermNet NZ. https://dermnetnz.org/topics/guidelines-for-the-treatment-of-psoriasis Website Accessed: 24th March
20. The Dermatologist. (2011). Assessing the Risks & Benefits of Biologic Therapies for Psoriasis. Available at
    https://www.hmpgloballearningnetwork.com/site/thederm/site/cathlab/event/assessing-risks-benefits-biologic-therapies-psoriasis Website Accessed: 5th April 2022.

Written by

Woong Yi Xin