Wednesday, February 4, 2015

Psoriasis Treatments



Treating your psoriasis is critical to good disease management and overall health. Work with your doctor to find a treatment—or treatments—that reduce or eliminate your symptoms. What works for one person with psoriasis might not work for another. So it's important to know the different treatment options and keep trying until you find the right regimen for you.

Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs

Biologic drugs, or "biologics," are given by injection or intravenous (IV) infusion. A biologic is a protein-based drug derived from living cells cultured in a laboratory. While biologics have been used to treat disease for more than 100 years, modern-day techniques have made biologics much more widely available as treatments in the last decade.
Biologics are different from traditional systemic drugs that impact the entire immune system. Biologics, instead, target specific parts of the immune system. The biologics used to treat psoriatic disease block the action of a specific type of immune cell called a T cell, or block proteins in the immune system, such as tumor necrosis factor-alpha (TNF-alpha), interleukin 17-A, or interleukins 12 and 23. These cells and proteins all play a major role in developing psoriasis and psoriatic arthritis.

Biosimilar substitution

The National Psoriasis Foundation Medical Board has issued a statement on biosimilar substitution. Read the statement »

Tumor necrosis factor-alpha (TNF-alpha) blockers

Cimzia (certolizumab pegol), Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab) and Simponi (golimumab) are drugs that block TNF-alpha. TNF-alpha is a cytokine, or a protein, that prompts the body to create inflammation. In psoriasis and psoriatic arthritis, there is excess production of TNF-alpha in the skin or joints. That leads to the rapid growth of skin cells and/or damage to joint tissue. Blocking TNF-alpha production helps stop the inflammatory cycle of psoriatic disease.

Interleukin 12/23

Stelara (ustekinumab) works by selectively targeting the proteins, or cytokines, interleukin-12 (IL-12) and interleukin 23 (IL-23). Interleukins-12/23 are associated with psoriatic inflammation.

Interleukin 17-A

Cosentyx (secukinumab) binds to and inhibits a cytokine, or protein, called interleukin-17A (IL-17A), which is involved in inflammatory and immune responses. There are elevated levels of IL-17A in psoriatic plaques. By inhibiting cytokines that trigger inflammation, Cosentyx interrupts the inflammatory cycle of psoriasis. This can lead to improvement in symptoms for many people who take it.

How are they used?

The biologics are taken by injection or by IV infusion. Cimzia, Cosentyx, Enbrel, Humira and Simponi are injected in the legs, abdomen or arms, typically by the individual with psoriatic disease or a family member. Stelara is administered as a subcutaneous injection by a health care provider. Remicade is given through IV infusion in a doctor’s office or infusion center. Biologics are prescribed for individuals with moderate to severe cases of plaque psoriasis and psoriatic arthritis. They are a viable option for those who have not responded to or have experienced harmful side effects from other treatments. Studies show that TNF-alpha blockers help reduce the progression of joint damage in psoriatic arthritis.

Do not take biologics if:

  • Your immune system is significantly compromised;
  • You have an active infection.
Screening for tuberculosis (TB) or other infectious diseases is required before starting treatment with Cosentyx, Enbrel, Humira, Remicade, Simponi and Stelara.

What are the risks?

Anyone considering taking a biologic drug should talk with his or her doctor about the short- and long-term side effects and risks. It is important to weigh the risks against the benefits of using the drugs.
Biologics can increase the risk of infection. Individuals who develop any sign of an infection such as a fever, cough or flu-like symptoms or have any cuts or open sores should contact their doctor right away.
The impact of biologics on developing fetuses or nursing infants is not known. Biologics should only be prescribed to pregnant or nursing women if there is a clear medical need.
Common side effects for biologics include:
  • Respiratory infections
  • Flu-like symptoms
  • Injection site reactions
These side effects are generally mild and in most cases do not cause individuals to stop taking the medication.
Rare side effects for biologics include:
  • Serious nervous system disorders, such as multiple sclerosis, seizures, or inflammation of the nerves of the eyes;
  • Blood disorders;
  • Certain types of cancer.
Call your doctor if you are experiencing any side effects with biologic drugs. For specific side effect information, download the individual product fact sheet.

Using biologics with other psoriasis treatments

All the current biologics can be used with other treatments such as phototherapy or topicals, though using phototherapy along with Remicade may increase skin cancer risk.
Cimzia, Enbrel, Humira and Remicade are shown to be safe and effective when taken with methotrexate. Talk to your doctor about whether using any other treatments with a biologic is right for you.
Traditional Systemic Medications
Systemic medications are prescription drugs that work throughout the body. They are usually used for individuals with moderate to severe psoriasis and psoriatic arthritis. Systemic medications are also used in those who are not responsive or are unable to take topical medications or UV light therapy.

Systemic psoriasis drugs are taken by mouth in liquid or pill form or given by injection. Systemics have been used for more than 10 years.

Download the Systemic Medications Booklet (pdf) »

Phototherapy

Phototherapy or light therapy, involves exposing the skin to ultraviolet light on a regular basis and under medical supervision. Treatments are done in a doctor's office or psoriasis clinic or at home with phototherapy unit. The key to success with light therapy is consistency.
National Psoriasis Foundation does not support the use of indoor tanning beds as a substitute for phototherapy performed with a prescription and under a doctor's supervision. Indoor tanning raises the risk of melanoma by 59 percent, according to the American Academy of Dermatology and the World Health Organization, and does not provide the type of light that most effectively treats psoriasis. Read more on the Psoriasis Foundation position on indoor tanning beds »

Find a provider who offers phototherapy in our Health Care Provider Directory »


Ultraviolet light B (UVB)

UVB phototherapy

Present in natural sunlight, ultraviolet B (UVB) is an effective treatment for psoriasis. UVB penetrates the skin and slows the growth of affected skin cells. Treatment involves exposing the skin to an artificial UVB light source for a set length of time on a regular schedule. This treatment is administered in a medical setting or at home.
There are two types of UVB treatment, broad band and narrow band. The major difference between them is that narrow band UVB light bulbs release a smaller range of ultraviolet light. Narrow-band UVB is similar to broad-band UVB in many ways. Several studies indicate that narrow-band UVB clears psoriasis faster and produces longer remissions than broad-band UVB. It also may be effective with fewer treatments per week than broad-band UVB.
During UVB treatment, your psoriasis may worsen temporarily before improving. The skin may redden and itch from exposure to the UVB light. To avoid further irritation, the amount of UVB administered may need to be reduced. Occasionally, temporary flares occur with low-level doses of UVB. These reactions tend to resolve with continued treatment.
UVB can be combined with other topical and/or systemic agents to enhance efficacy, but some of these may increase photosensitivity and burning, or shorten remission. Combining UVB with systemic therapies may increase efficacy dramatically and allow for lower doses of the systemic medication to be used.

Home UVB phototherapy

Treating psoriasis with a UVB light unit at home is an economical and convenient choice for many people. Like phototherapy in a clinic, it requires a consistent treatment schedule. Individuals are treated initially at a medical facility and then begin using a light unit at home.
It is critical when doing phototherapy at home to follow a doctor's instructions and continue with regular check-ups. Home phototherapy is a medical treatment that requires monitoring by a health care professional.
All phototherapy treatments, including purchase of equipment for home use, require a prescription. Some insurance companies will cover the cost of home UVB equipment. Vendors of home phototherapy equipment often will assist you in working with your insurance company to purchase a unit.

Sunlight

Although both UVB and ultraviolet light A (UVA) are found in sunlight, UVB works best for psoriasis. UVB from the sun works the same way as UVB in phototherapy treatments.
Short, multiple exposures to sunlight are recommended. Start with five to 10 minutes of noontime sun daily. Gradually increase exposure time by 30 seconds if the skin tolerates it. To get the most from the sun, all affected areas should receive equal and adequate exposure. Remember to wear sunscreen on areas of your skin unaffected by psoriasis.
Avoid overexposure and sunburn. It can take several weeks to see improvement. Have your doctor check you regularly for sun damage.
Some topical medications can increase the risk of sunburn. These include tazarotene, coal tar, Elidel (pimecrolimus) and Protopic (tacrolimus). Individuals using these products should talk with a doctor before going in the sun.
People who are using PUVA or other forms of light therapy should limit or avoid exposure to natural sunlight unless directed by a doctor.

Psoralen + UVA (PUVA)

Like UVB, ultraviolet light A (UVA) is present in sunlight. Unlike UVB, UVA is relatively ineffective unless used with a light-sensitizing medication psoralen, which is administered topically or orally. This process, called PUVA, slows down excessive skin cell growth and can clear psoriasis symptoms for varying periods of time. Stable plaque psoriasis, guttate psoriasis, and psoriasis of the palms and soles are most responsive to PUVA treatment.
The most common short-term side effects of PUVA are nausea, itching and redness of the skin. Drinking milk or ginger ale, taking ginger supplements or eating while taking oral psoralen may prevent nausea. Antihistamines, baths with colloidal oatmeal products or application of topical products with capsaicin may help relieve itching. Swelling of the legs from standing during PUVA treatment may be relieved by wearing support hose.

Laser Treatments

Excimer laser

The excimer laser—recently approved by the Food and Drug Administration (FDA) for treating chronic, localized psoriasis plaques—emits a high-intensity beam of ultraviolet light B (UVB).
The excimer laser can target select areas of the skin affected by mild to moderate psoriasis, and research indicates it is a particularly effective treatment for scalp psoriasis. Researchers at the University of Utah, for example, reported in The Journal of Drugs in Dermatology that in a small series of patients, laser treatment, combined with a topical steroid, cleared scalp psoriasis that resisted other treatment.
Individual response to the treatment varies. It can take an average of four to 10 sessions to see results, depending on the particular case of psoriasis. It is recommended that patients receive two treatments per week, with a minimum of 48 hours between treatments.
There is not yet enough long-term data to indicate how long the improvement will last following a course of laser therapy.

Pulsed dye laser

Like the excimer laser, the pulsed dye laser is approved for treating chronic, localized plaques. Using a dye and different wavelength of light than the excimer laser or other UVB-based treatments, pulsed dye lasers destroy the tiny blood vessels that contribute to the formation of psoriasis lesions.
Treatment consists of 15- to 30-minute sessions every three weeks. For patients who respond, it normally takes about four to six sessions to clear the target lesion.
The most common side effect is bruising after treatment, for up to 10 days. There is a small risk of scarring.

Tanning beds

Some people visit tanning salons as an alternative to natural sunlight. Tanning beds in commercial salons emit mostly UVA light, not UVB. The beneficial effect for psoriasis is attributed primarily to UVB light. National Psoriasis Foundation does not support the use of indoor tanning beds as a substitute for phototherapy performed with a prescription and under a doctor's supervision. Read more on the Psoriasis Foundation position on indoor tanning beds »
The American Academy of Dermatology, the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention all discourage the use of tanning beds and sun lamps. Indoor tanning raises the risk of melanoma by 59 percent, according to the American Academy of Dermatology and the World Health Organization. In May 2014, the FDA reclassified sunlamps (which are used in tanning beds and booths) from Class I (low risk) to Class II (moderate risk) products. The FDA can exert more regulatory control over Class II products, according to a press release on the FDA website.
The ultraviolet radiation from these devices can damage the skin, cause premature aging and increase the risk of skin cancer.

New Oral Treatments

New oral treatment options have emerged with a sophisticated approach to treating psoriatic disease. These so-called "small-molecule" treatments can be delivered effectively by mouth. Unlike earlier pills used for psoriasis and psoriatic arthritis, these new oral treatments selectively target molecules inside immune cells. By adjusting the complicated processes of inflammation within the cell, these treatments correct the overactive immune response that causes inflammation in people with psoriasis and psoriatic arthritis,, leading to improvement in redness and scaliness as well as joint tenderness and swelling.

Otezla

The newest available oral treatment for psoriasis and psoriatic arthritis is Otezla (apremilast). Otezla treats psoriatic arthritis by regulating inflammation within the cell. It inhibits an enzyme known as phosphodiesterase 4, or PDE4. PDE4 controls much of the inflammatory action within cells, which can affect the level of inflammation associated with psoriatic disease.
By helping to control inflammation in this way, Otezla improves joint tenderness and swelling in people with active psoriatic arthritis, and can improve symptoms of redness and scaliness in people with psoriasis.

How is it used?

Otezla is available as a 30-milligram (mg) tablet. The first five days is a start period, where the dosage will gradually increase over five days until the recommended dose of 30 milligrams twice daily is reached. Otezla is designed to be taken continuously to maintain improvement.

What are the risks?

In clinical trials, 10 to 12 percent of people taking Otezla reported unexplained weight loss of 5 to 10 percent during their trial period. It is recommended that people taking Otezla have their weight monitored regularly.
In clinical trials, approximately 6.1 percent of the people taking Otezla for psoriasis discontinued treatment due to an adverse reaction.

Common side effects

In clinical trials, the most common side effects were diarrhea, nausea and headache, which occurred in the first two weeks and tended to lessen with continued treatment.

Using Otezla with other treatments

Otezla can be used with other treatments such as phototherapy or topicals. It has been shown to be safe and effective when taken with methotrexate. Talk to your doctor about whether using any other treatments with Otezla is right for you.

Topical Treatments

Topical treatments—medications applied to the skin—are usually the first line of defense in treating psoriasis. Topicals slow down or normalize excessive cell reproduction and reduce psoriasis inflammation.
There are several effective topical treatments for psoriasis. While many can be purchased over the counter (OTC), others are available by prescription only.
Corticosteroids, or just "steroids," are the most frequently used treatment for psoriasis. They are referred to as anti-inflammatory agents, because they reduce the swelling and redness of lesions. Anthralin, synthetic vitamin D3, and vitamin A are also used in prescription topical treatments to control psoriasis lesions.
OTC topicals come in many different forms. Two active ingredients, salicylic acid and coal tar, are approved by the FDA for the treatment of psoriasis. There are other products that contain substances such as aloe vera, jojoba, zinc pyrithione and capsaicin, which are used to moisturize, soothe, remove scale or relieve itching.


Complementary and Alternative Therapies
Many patients today with chronic conditions, including psoriasis and psoriatic arthritis, have an interest in complementary and alternative therapies—these focus more on preventative care and pain management.
Surveys for the National Center for Complementary and Alternative Medicine (NCCAM) and National Center for Health Statistics (part of the Center for Disease Control and Prevention) show more than a third of Americans (36 percent) use complementary and alternative therapies. These therapies include diet, herbs and supplements, mind/body therapies such as aromatherapy, yoga and meditation, physical therapies, exercise and the ancient arts of acupuncture and tai chi.
Much of the evidence supporting complementary and alternative therapies for psoriasis and psoriatic arthritis is anecdotal. Increasingly, researchers have studied complementary and alternative therapies particularly in looking at drug interactions, dietary outcomes and safety. Most complementary and alternative therapies are safe. However, some can interfere with your treatments prescribed by your doctor.
Always talk to your doctor or consult with a licensed health care professional before adding any complementary and alternative treatments to your treatment plan for psoriasis and psoriatic arthritis.

Find a Naturopathic Physician

Need help sorting through alternative treatments? Naturopathic physicians use diet, exercise, lifestyle changes and natural therapies to promote wellness in their patients’ lives and help with disease management or minimize side effects from other therapies. Locate a licensed naturopathic doctor near you »

Diet and NutritionDiet and Nutrition

Many people with psoriasis have no doubt suspected what they eat affects their condition. Some find eliminating certain foods can help their psoriasis to clear. Learn more about certain foods that can help relieve symptoms. View more about diet and nutrition »

Herbal RemediesHerbal Remedies

Many herbal remedies have become mainstream in recent years. Don't mistake the terms "herbal" or "natural" or safe. Read more about herbal remedies »

Mind/Body TherapiesMind/Body Therapies

Mind-body techniques can help reduce your stress levels. Learn about mind/body therapies »

Alternative TherapiesAlternative Therapies

Some psoriasis patients report hands-on alternative therapies can help relieve their psoriasis and psoriatic arthritis symptoms. More about alternative therapies »

ExerciseExercise

Physical activity is important for your overall health and especially so if you have psoriasis or psoriatic arthritis. Exercise can help you maintain a healthy weight and lower your risk of heart disease and type 2 diabetes. Your risk for heart disease and type 2 diabetes is increased when you have psoriasis. Read more »

Yoga and Tai ChiYoga and Tai Chi

Yoga combines controlled breathing, stretching and strengthening exercises, and meditation to help control stress and improve blood flow to areas affected by psoriasis. Like yoga, Tai Chi is an ancient Chinese art that can be effective in treating arthritis. Learn more »