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• Highlights
• Introduction
• Causes
• Risk Factors
• Prognosis
• Diagnosis
• Treatment
• Topical Medications
• Other Medications
• Phototherapy
• Managing Psoriasis
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Psoriasis

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of psoriasis.

Topical Medications

Topical medications are those applied only to the surface of the body. They come in the following forms:

• Ointments
• Gels
• Solutions
• Creams
• Sprays
• Foams
• Lotions
• Shampoos
• Occlusive tapes

In general, topical treatments are the first line for mild-to-moderate psoriasis, but they may also be used, alone or in combination, with more powerful treatments for moderate-to-severe cases.

Topical Corticosteroids

Benefits. Corticosteroid topical treatments are the mainstays of psoriasis treatments in the US, and are effective for most patients. They have many benefits, including the following:

• They reduce inflammation
• They inhibit cell proliferation
• They relieve itching (sometimes itching can also be a side effect of the drug itself, however)

Brands differ in potency (strength), and many are available in numerous forms, including lotions, solutions, creams, emollient creams, ointments, gels, sprays, and on tape. Foam preparations are in particular making compliance (following treatment recommendations) much easier. Injections of certain steroids, such as triamcinolone, may help treat nail psoriasis.

Corticosteroids are available in a wide range of potencies, generally given as follows:

• Less potent drugs should be used for mild-to-moderate psoriasis.
• Higher-potency agents are suitable for more severe disease.

Topical Treatment. An example of a topical treatment that uses a single agent is as follows:

• Patients use a high-potency topical corticosteroid, such as halobetasol (Ultravate) daily, until the psoriasis plaque flattens out. This is the transitional phase.
• After the transitional phase, the patient uses the medicine only on the weekends for maintenance.

In the past, topical steroids have been used twice a day. Studies are reporting, however, that certain agents can be used effectively only once daily. Most studies have used high-potency steroids, but a 2001 study suggested that medium-potency agents, such as triamcinolone (Aureocort, Tri-Adcortyl), may be equally beneficial as a once-daily treatment. In any case, however, corticosteroids used alone are effective in clearing psoriasis in only 4 - 36% of patients.

Combinations with other drugs are often needed. For example, an effective, topical regimen uses the following combination for maintenance therapy:

• A high-potency steroid (e.g., halobetasol) on the weekend
• The vitamin D3 topical agent, calcipotriene, twice daily on weekdays

In one study, over three-quarters of patients with mild-to-moderate psoriasis remained in remission for at least 6 months with this regimen.

Side Effects. The more powerful a drug, the more effective it is. But it also has a higher risk for severe side effects. They can include the following:

• Burning
• Irritation
• Dryness
• Acne
• Thinning of the skin; skin may become shiny, fragile, and easily cut
• Dilated (widened) blood vessels
• Loss of skin color

Do not use corticosteroids during pregnancy or nursing. The high-potency drugs carry a small risk for adrenal insufficiency , which is usually mild. If this occurs, the body loses its ability to produce natural steroid hormones for a period of time after the drug has been withdrawn, which can cause serious complications. With topical steroids, however, this event is uncommon and usually mild.

Loss of Effectiveness. In most cases, the patients become tolerant to the effects of the drugs, and the drugs become ineffective. Some experts recommend using intermittent therapy (also called weekend or pulse therapy). This type of treatment involves applying a high-potency topical agent for 3 full days each week. In one study, intermittent treatment maintained improvement for 6 months in 60% of patients.

Some Topical Corticosteroids Used for Psoriasis
Low potency (some are available over the counter)	Hydrocortisone low potency (Hytone, Penecort, Synacort, Cort-Dome, Nutracort, Westcort) Desonide (Tridesilon, DesOwen) Flumethasone pivalate (Locorten) Fluocinolone acetonide (Synalar, Derma-Smoothe) Triamcinolone acetonide (Aristocort)
Low to medium potency	Alclometasone dipropionate (Aclovate) Hydrocortisone low to medium potency (Locoid, Pandel) Hydrocortisone valerate (Westcort) Prednicarbate (Dermatop)
Medium to upper-mid potency	Clocortolone pivalate (Cloderm) Fluticasone propionate (Cutivate). A low-dose ointment (0.005%) is proving to be effective for psoriasis on the face and in folds of the skin, but not in other areas. Mometasone furoate (Elocon). This drug is used only once a day. May be as or more effective than other corticosteroids at the same strength, while having a lower risk for severe side effects. Triamcinolone acetonide (Aureocort, Tri-Adcortyl, Kenalog). Available as a topical cream or as an injectable agent to treat nail psoriasis.
High potency	Betamethasone (Diprosone) -- also available in lower potencies. Amcinonide (Cyclocort) Desoximetasone (Topicort) Diflorason diacetate (Florone, Maxiflor) Fluocinonide (Lidex) Halcinonide (Halog)
Very high potency	Halobetasol propionate (Ultravate) Betamethasone (Diprolene) -- available as a foam (Luxiq). Clobetasol propionate (Temovate) -- also available as a foam (Olux). Diflorasone diacetate (Florone, Maxiflor, Psorcon). Psorcon is a gel form that may be particularly helpful.

Coal Tar

Coal tar preparations have been used for psoriasis for about 100 years, although their use has declined with the introduction of topical vitamin D3-related medicines. Crude coal tar stops the action of enzymes that contribute to psoriasis, and helps prevent new cell production. Tar is often used in combination with other drugs and with ultraviolet B (UVB) phototherapy.

Side Effects. Preparations have the following drawbacks:

• The drug can cause sun sensitivity, and increase the risk of sunburn for up to 24 hours after use.
• It has a strong smell.
• It can stain clothing.
• It irritates the skin.
• Ingesting the medication is life threatening. In such cases, call poison control immediately.

Anthralin

Benefits. Anthralin (Dritho-Scalp, Drithocreme, Micanol), called dithranol in Europe, is related to a traditional medication called chrysarobin, in use since the early 1900s. Anthralin slows skin cell reproduction and can produce remissions that last for months. It is recommended only for chronic or inactive psoriasis, not for acute or inflamed eruptions.

Side Effects. As with tar, its use has also declined with introduction of the topical vitamin D-related medicines, but newer formulations, such as Micanol, have made its use more tolerable. Micanol (Psoriatec) is an anthralin formulated in micro-capsules, which dissolve and allow the drug to be delivered directly to the target skin areas. It is particularly useful for scalp psoriasis, and it is less likely to stain, unlike anthralin.

• Skin irritation and burning: Patients should not use anthralin on the face. Fair skinned people should generally avoid it. Triethanolamine (CuraStain) is a chemical that can neutralize anthralin and help reduce irritation from short-contact anthralin treatment. It should be applied a minute or two before washing off the anthralin. It is then reapplied after drying the skin.
• Brown staining: Older forms of anthralin, such as Drithocreme, can stain hair, fabrics, plastics, and other household products. Micanol does not stain household products if used with cool water. Washing stained items with hypochlorite (Clorox) detergents can help remove stains.
• Although topical preparations do not appear to affect areas other than the skin, people with kidney problems should use anthralin with caution.

Application. Apply anthralin only to the psoriasis plaques. Many people use disposable gloves to avoid staining hands. The areas can usually be protected with dressings. Rub the cream in well, and wipe off any excess. Wash off only with lukewarm water, not soap. Using hot water will trigger the staining action. A technique called short-contact anthralin therapy (SCAT), also called minute therapy, is useful for local areas of psoriasis. In such cases, anthralin is applied for only 10 minutes to an hour.

Topical Vitamin D3-Related Treatments

A topical (rub-on) form of vitamin D3, calcipotriene (Dovonex), called calcipotriol in Europe, is proving to be both safe and effective. It is now available in a foam preparation, which makes compliance even easier. Several other topical vitamin D3 analogs (related drugs) showing promise include maxacalcitol (Oxarol), tacalcitol, and calcitriol (Silkis), the active form of vitamin D.

Benefits. Calcipotriene has the following benefits:

• It appears to help block skin cell multiplication.
• It enhances the maturity of keratinocytes (the impaired skin cells in psoriasis).
• It has anti-inflammatory properties.

It is at least as effective as moderate topical corticosteroids, short contact anthralin, and coal tar in improving mild to moderate plaque psoriasis. Unlike steroids, patients do not develop thinning of the skin or tolerance to the drug.

Combinations. Combinations with other topical and oral treatments may improve effectiveness.

• Calcipotriene is not as effective as the highest potency corticosteroids, but products or regimens that combine both agents are proving to be more effective than either agent alone. An ointment containing a combination of the drugs calcipotriol and betamethasone was approved by the Food and Drug Administration (FDA) in January 2006 for the treatment of adults with psoriasis. The product, marketed in the U.S. as Taclonex, was more effective in clinical studies than either drug alone.
• Studies also report success in some patients who use vitamin D ointments in combination with phototherapy treatment.
• Combining vitamin D ointments with oral agents, notably methotrexate, acitretin, or cyclosporine, increases effectiveness and allows lower doses or either medication, thereby reducing side effects.

Side Effects of calcipotriene include the following:

• Calcipotriene causes skin irritation in about 20% of patients, particularly on the face and in skin folds. In fact, it causes greater skin irritation than potent corticosteroids. Diluting the drug with petrolatum or applying topical corticosteroids to sensitive areas may prevent this problem.
• Although the drug appears to be safe and effective in children, there is some concern that it may lower levels of vitamin D to the extent that it could affect bone growth. More studies are needed to assess this effect.
• There have been some reports of hypercalcemia (too much calcium in the blood) in some people who apply calcipotriene to large areas.

Topical Retinoids

Retinoids are related to vitamin A. They are used for various skin disorders. Tazarotene (Tazorac) is the first topical retinoid found to be effective for mild-to-moderate psoriasis. It is available in cream or gel from.

Benefits. Tazarotene benefits the targeted skin tissue without causing the bad body-wide effects of oral retinoids. Also unlike steroids, patients do not develop thinning of the skin or tolerance to the drug. Only a very small amount is needed on each lesion. It can be used on the scalp and nails, but it is not recommended for the genital areas or around the eyes. The gel should be used on only 20% of the body at anytime, the cream on up to 35%. As mentioned above, the palm of the hand is about 1% of the body surface.

Side Effects. Tazarotene can cause dryness and irritation on normal skin. Applying zinc oxide around the treated area can protect the healthy skin. Using a moisturizer can help reduce dryness. At levels high enough to be effective for psoriasis, tazarotene can cause severe skin irritation. This medicine, then, is usually used in combination with other treatments, therefore allowing a lower dose. Mixing the drug in equal amounts with petroleum jelly (Vaseline) initially and then gradually increasing the amount of tazarotene may help the skin areas become less sensitive. It should be noted that the skin can become very red while it is actually improving.

Vitamin A derivatives (drugs related to vitamin A) have been associated with birth defects, and the drug should not be used by women who are pregnant, who wish to conceive, or who are nursing.

Combinations. Combinations, such as with topical steroids or phototherapy, are more effective than the use of the drug alone. Unlike vitamin D3, phototherapy with either UVA or UVB inactivates this medicine, although there is a higher risk for sunburn with this combination.

Salicylic Acid

Topical salicylic acid is useful for removing scaly plaque and enhancing other agents. It should not be used to cover wide areas of the body, since it can cause nausea and ringing in the ears. Combinations with high potency steroids, such as mometasone furoate (Combisor), clobetasol propionate, and betamethasone, are proving to be very helpful. Only Combisor is available in the US.

Occlusive Tapes Watertight (occlusive) tapes or wrappings may help heal psoriasis. Occlusive tapes are particularly useful for psoriatic cuts on the palms and soles. (In such cases, the tape should be applied across the cuts until they heal.) Occlusive tapes retain sweat, which helps restore moisture to the outer skin layer and prevent scaling. They also protect against abrasion and irritation. High-Potency Corticosteroid Tapes. Applying a corticosteroid beneath an occlusive tape, or using a tape that already has a potent corticosteroid (Cordran Tape), such as flurandrenolide, may be especially beneficial. Studies are showing that high-potency corticosteroid-impregnated tapes (tapes that have corticosteroids in them) are more effective than using high-potency corticosteroid ointments alone. The downsides are: The corticosteroid-impregnated tape is expensive. It produces a higher rate of skin irritation than the ointment alone. It produces worse rebound effects (a relapse of symptoms after stopping treatment) than the ointment. Steroid-impregnated tapes increase the risk for secondary infections, which may be prevented by changing the tapes every 12 hours. The use of corticosteroids under occlusive materials on large areas of psoriasis increases the risk for adrenal insufficiency, a sometimes dangerous condition that occurs because the body loses its ability to produce natural steroids. Children are especially vulnerable to this effect. Other Medications with Occlusive Tapes or Wrappings. One study applied a cream containing fluorouracil underneath an occlusive tape. Fluorouracil is a powerful medication that interferes with cell growth. The dressing was applied two or three times a week for an average of about 16 weeks and resulted in 90% clearing in 11 out of 15 patients. Improvement lasted beyond 3 months in five patients. Dovonex is also sometimes used with an occlusive wrapping. Occlusive wrappings are not usually used with tazarotene (Tazorac) and should never be used without a doctor's recommendation.

Investigative Topical Agents

Numerous topical agents are under investigation. One such agent, tacrolimus (Protopic), is an immunosuppressant that is proving to be useful in allergic skin disorders and is being studied for psoriasis. Studies have been mixed on its benefits, although new delivery methods may make it more effective. It may prove to be safe for sensitive areas, such as the face. Pimecrolimus (Elidel), a similar agent, is also being studied.

• Review Date: 10/30/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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