Affecting an estimated 7.5 million people in the United States, psoriasis is one of the more common disease states that dermatologists treat. Psoriasis is a chronic inflammatory disorder that affects both the skin and joints, which can be accompanied by both significant emotional and psychological implications. The cutaneous disease commonly affects the scalp and extensor surfaces of extremities such as the elbows and knees, however, all body surface areas may be affected. Patients may also experience joint disease, which can be severely debilitating as the arthritis is progressive and destructive. Given the complexity of this disease, it is essential that the dermatologist looks at all components and addresses the whole needs of the patient thereby insuring not only their physical well-being, but enhancing their overall quality of life as well.
Traditional treatment may consist of topical medications such as creams and lotions. Corticosteroid creams can be effective, but may have long term consequences such as skin atrophy or thinning. Other topical medications, such as Vitamin D creams and Vitamin A creams known as retinoids, may also help break down persistent thick plaques. For larger body surface areas, sprays and foams are available which can make the application more convenient.
Ultraviolet light is another treatment modality, and can be obtained naturally or in specially designed UV photo booths. A newer light therapy that is available is the Excimer laser, which is a concentrated UVB source. Treatments are painless, and be performed quickly in the office over a course of sessions to gradually improve the skin disease. Treatments can be customized for the patient and include topical or systemic medications for the best clinical outcome.
For the more severe disease, systemic medications are available. Older medications such as methotrexate and cyclosporine, although effective, are associated with side effects including liver and kidney issues. Over the past decade, there has been a better understanding of the underlying inflammatory pathways that directly cause psoriasis. There are now several biological treatments which target these specific inflammatory pathways of psoriasis. These medications are more effective for both the cutaneous and arthritic components and are also associated with significantly less side effects. Enbrel was one of the first available, and is delivered to a patient through an easy subcutaneous injection. Following the success of this medication, Humira and Stelara, also subcutaneous injections soon became available. Each of these have had dramatic success for both the skin and joint disease which correlates to overall improvement in the quality of life.
For patients who have an aversion to needles, there is a new oral medication Otezla. This medication blocks a different inflammatory pathway, but still has moderate success with psoriatic skin disease and arthritis. The newest biological injectables on the market are termed IL-17 blockers which target a new inflammatory pathway. They initially have been reported to have high clearance rates of psoriasis and can be useful for patients who have failed treatment with earlier biologic medications.
Over the past decade, there has been significant advancement of treatment of psoriatic disease. When I was a resident 20 years ago, the severe psoriatic patients were often hospitalized. With the continual development and advancement of biologic psoriatic medications, this inpatient regimen will hopefully be a thing of the past. I have seen the results of the new treatments first hand, as my mother suffers severe psoriatic arthritis. When her psoriatic arthritis was severe, activities such as walking were a daily challenge. Although she had been treated with other systemic medications in the past, the side effects forced her to look at new options. After recently beginning the newer biologic injections, she is now nearly pain free, and able to travel and enjoy activities of daily living that many of us take for granted.
