There can be substantial variation between individuals in the effectiveness of specific psoriasis treatments. Because of this, dermatologists often use a trial-and-error approach to finding the most appropriate treatment for their patient. The decision to employ a particular treatment is based on the type of psoriasis, its location, extent and severity. The patient’s age, gender, quality of life, comorbidities, and attitude toward risks associated with the treatment are also taken into consideration.
Illustration of psoriasis treatment ladderMedications with the least potential for adverse reactions are preferentially employed. If the treatment goal is not achieved then therapies with greater potential toxicity may be used. Medications with significant toxicity are reserved for severe unresponsive psoriasis. This is called the psoriasis treatment ladder. As a first step, medicated ointments or creams are applied to the skin. This is called topical treatment. If topical treatment fails to achieve the desired goal then the next step would be to expose the skin to ultraviolet (UV) radiation. This type of treatment is called phototherapy. The third step involves the use of medications which are ingested orally or by injection. This approach is called systemic treatment.
Over time, psoriasis can become resistant to a specific therapy. Treatments may be periodically changed to prevent resistance developing and to reduce the chance of adverse reactions occurring. This is called treatment rotation.
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Topical treatment
Bath solutions and moisturizers help sooth affected skin and reduce the dryness which accompanies the build-up of skin on psoriasis plaques. Medicated creams and ointments applied directly onto psoriasis plaques can help reduce inflammation, remove the build-up of scale, reduce skin turn over, and clear affected skin of plaques. Ointment and creams containing coal tar, anthralin, corticosteroids, vitamin D3 analogues, and retinoids are routinely used. The mode of action of each is probably different but they all help to normalise skin cell production and reduce inflammation. Topical agents can irritate normal skin. This section briefly describes commonly used topical agents.
Moisturizers and bath solutions when used regularly have a soothing effect and help to remove the build-up of dry skin.
Salicylic acid is a peeling agent which helps to reducing scaling of the skin or scalp. It is often added to ointments, creams, gels, and shampoos.
Coal tar preparations are often applied directly to the skin, added to bath water, or used as a shampoo. Coal tar increases the skin's sensitivity to light and is sometimes combined with ultraviolet B (UVB) phototherapy. Coal tar is messy, has a strong odour, and may stain the skin or clothing.
Anthralin (Dithranol) is applied for short periods of time and then washed off to prevent irritation. This treatment often stains skin, clothing and bathtub purple.
Look
http://www.psoriasis.org/
http://www.nlm.nih.gov/medlineplus/psoriasis.html
http://www.rdoctor.com
http://www.symptomat.com
http://www.kavokin.com
http://en.wikipedia.org/wiki/Psoriasis
Corticosteroids are available in different strengths. Long-term use of potent corticosteroids is discouraged as this can cause thinning of the skin, internal side effects, and resistance to the treatment's benefits. It is possible for psoriasis to be aggravated on ceasing steroid treatment, particularly after long term use (rebound effect).
Calcipotriol (Calcipotriene (USAN)) is a synthetic form of vitamin D3. It is not recommended for use on folds of skin or on the face. Overuse can cause high levels of calcium in the blood (hypercalcemia). Calcipotriol combined with betamethasone dipropionate, a steroid, is more effective than the two products used separately.
Retinoids are synthetic forms of vitamin A. The retinoid tazarotene (Tazorac) is available as a gel or cream that is applied to the skin. Retinoids are teratogenic, and are not recommended for women of childbearing age.
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Phototherapy
Natural ultraviolet light from the sun and controlled delivery of artificial ultraviolet light have a therapeutic effect on psoriasis.
Sunlight contains many different wavelengths of ultraviolet (UV) light. UV wavelengths are subdivided into UVA (380–315 nm), UVB (315–280 nm), and UVC (< 280 nm). UVA and UVB are beneficial in treating psoriasis. When absorbed by the skin, UV light is thought to suppress the immune-mediated processes involved in psoriasis. Daily, short, nonburning exposure to sunlight can therefore help to clear or improve psoriasis.
Ultraviolet B (UVB) (315–280 nm) is absorbed by the epidermis and has a beneficial effect on psoriasis. Narrowband UVB (311 to 312 nm), is that part of the UVB spectrum that is most helpful for psoriasis. Narrowband UVB treatment is thought to be superior than using the full UVB spectrum. Exposure to UVB several times per week, over several weeks may be required to attain a remission.
In contrast to full body exposure, targeted multiwavelength systems deliver narrow band UVB to psoriatic lesions through a fibre optic delivery system. Only psoriatic lesions are targeted and normal skin is not exposed to the harmful effects of UVB. This method of delivering UVB is of limited use when psoriasis is extensive.
Psoralen and ultraviolet A phototherapy (PUVA) combines the administration of a medicine called psoralen with exposure to ultraviolet A (UVA) light. UVA penetrates deeper into the skin than UVB. Psoralen makes the skin more sensitive to UVA. Compared with broadband UVB treatment, PUVA clears psoriasis more consistently and in fewer treatments. However, it is associated with nausea, headache, fatigue, burning, and itching. Care must be taken to avoid sunlight after ingesting psoralen to avoid sunburn, and the eyes must be protected with UVA-absorbing glasses. Long-term treatment is associated with squamous-cell and melanoma skin cancers.
Ultraviolet light treatment is frequently combined with topical (coal tar, calcipotriol) or systemic treatment (retinoids) as there is a synergy in their combination. One combined therapy program, referred to as the Ingram regime, involves a coal tar bath, UVB phototherapy, and application of an anthralin-salicylic acid paste that is left on the skin for 6 to 24 hours. A similar regime, the Goeckerman treatment, combines coal tar ointment with UVB phototherapy.
A form of X-ray radiation called Grenz Rays was a popular form of treatment of psoriasis during the middle of the 20th century. This type of therapy was superseded by ultraviolet therapy and is no longer used in most countries.
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Systemic treatment
For psoriasis which is resistant to topical and phototherapy, doctors sometimes prescribe medications that are taken internally by pill or injection. This is called systemic treatment. Patients taking systemic therapy are often required to take regular blood tests because of the toxicity of the medications.
Retinoids, such as acitretin (Soriatane or Neotigason), are compounds with vitamin A-like properties. They are prescribed for severe cases of psoriasis that do not respond to other therapies. Because this treatment may also cause birth defects, women must protect themselves from pregnancy beginning 1 month before through 3 years after treatment with acitretin. Most patients experience a recurrence of psoriasis after these products are discontinued. Common side effects include dry lips, hands and feet. Use of retinoids in conjunction with UV treatments has been found to be very effective for some people.
Methotrexate slows cell turnover by suppressing the immune system. It can be taken by pill or injection. Patients taking methotrexate must be closely monitored because it can cause liver damage and/or decrease the production of oxygen-carrying red blood cells, infection-fighting white blood cells, and clot-enhancing platelets. As a precaution, doctors do not prescribe the drug for people who have had liver disease or anaemia (an illness characterized by weakness or tiredness due to a reduction in the number or volume of red blood cells that carry oxygen to the tissues). It is sometimes combined with PUVA or UVB treatments. Methotrexate should not be used by pregnant women, or by women who are planning to get pregnant, because it may cause birth defects.
Ciclosporin (also spelled as cyclosporin(e)) works by suppressing the immune system to slow the rapid turnover of skin cells. It may provide quick relief of symptoms, but the improvement stops when treatment is discontinued. The best candidates for this therapy are those with severe psoriasis who have not responded to, or cannot tolerate, other systemic therapies. Its rapid onset of action is helpful in avoiding hospitalisation of patients whose psoriasis is rapidly progressing. Ciclosporin may impair kidney function or cause high blood pressure (hypertension). Therefore, patients must be carefully monitored by a doctor. Also, ciclosporin is not recommended for patients who have a weak immune system or those who have had skin cancers as a result of PUVA treatments in the past. It should not be given with phototherapy.
Tioguanine has been reported to be nearly as effective as methotrexate and ciclosporin. It has fewer side effects, but there is a greater likelihood of anemia. This drug must also be avoided by pregnant women and by women who are planning to become pregnant, because it may cause birth defects.
Hydroxyurea (Hydrea) is somewhat more effective than methotrexate and ciclosporin. It is sometimes combined with PUVA or UVB treatments. Possible side effects include anaemia and a decrease in white blood cells and platelets. Like methotrexate and retinoids, hydroxyurea must be avoided by pregnant women or those who are planning to become pregnant, because it may cause birth defects. This is an extremely potent drug that was originally used to treat cancer patients in combination with chemotherapy.
Antibiotics are not indicated in routine treatment of psoriasis. However, antibiotics may be employed when an infection, such as that caused by the bacteria Streptococcus, triggers an outbreak of psoriasis, as in certain cases of guttate psoriasis.
Biologics[2] are the newest class of treatment for psoriasis. These are types of manufactured proteins that interrupt the immune process leading to psoriasis. Unlike generalised immunosuppressant therapies such as methotrexate, biologics focus on specific aspects of the immune function leading to psoriasis. These drugs are relatively new, and their long-term impact on immune function is unknown. Examples include Amevive®, etanercept (Enbrel®), Humira®, infliximab (Remicade®) and Raptiva.
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Alternative Therapy
Some people subscribe to the view that psoriasis can be effectively managed through a healthy lifestyle. This view is based on anecdote, and has not been subjected to formal scientific evaluation. Nevertheless, some people report that minimizing stress and consumption of alcohol, sugar and other "aggressive" foods, combined with rest, sunshine and swimming in saltwater keep lesions to a minimum. This type of "lifestyle" treatment is suggested as a long-term management strategy, rather than an initial treatment of severe psoriasis.
2006-07-05 00:10:39
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answer #7
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answered by MEdExp,MD 2
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