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| :: Psoriasis: Picking the Perfect Plan :: |
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Even though there are records of the skin disorder psoriasis dating back 2,000 years, only recently have people with psoriasis had more than a few moderately effective treatment options. These new therapies were developed after researchers realized that psoriasis results not from the skin itself but from a malfunction in the immune system.
So today, people living with the plaques or lesions that characterize psoriasis can choose from creams or ointments, light therapy or therapies that affect the immune system such as medications known as biologics. Below, Robert Greenberg, MD, of the East Bay Psoriasis Treatment Center in San Ramon, California, talks about how to select the best therapy for your needs.
What is psoriasis?
Psoriasis is an inflammatory disease of the skin. A long time ago, it was felt to be strictly a skin disorder, but because of some studies, we realized that it's actually an immune-mediated disorder that is showing itself in the skin. It is due to circulating immune system cells called T cells that cause inflammation in the skin that leads to skin thickening and red, scaly plaques.
What are the different stages of psoriasis?
The standard definition of severe psoriasis is psoriasis covering 10 percent total body surface area. My personal belief is 20 percent total body surface area would be considered severe, 10 to 20 percent would be moderate and less than 10 percent would be on the milder side.
What are the different types of psoriasis?
There are a few types of psoriasis and they look somewhat different. The most classic is called plaque psoriasis, where you get thick, scaly, red plaques, most commonly on the elbows, knees and the scalp. Other forms are pustular psoriasis, which causes pustules or lesions all over the skin. There's a form called guttate, which is very small, round patches. And also a form called inverse psoriasis, where you get lesions under the arms and in the groin folds.
Psoriatic arthritis is often seen with psoriasis and sometimes it's seen independently. It is an inflammation of the joints. You get swelling and redness, most particularly around the fingers, but it can involve the knees and elbows.
How can psoriasis affect quality of life?
Psoriasis can be a devastating disorder. Psychologically, patients feel often like lepers; they feel that they're not part of the community. They cannot participate in activities such as swimming at their local pool, playing tennis. Even socially, on dates for example, it's very awkward.
Most patients feel that the remainder of the world is not familiar with psoriasis. People think psoriasis may be contagious and they can catch it from them. I recently had a patient who worked at a physical fitness center and many of her clients would not come back to her when she had a flare of her psoriasis.
What kinds of therapy are available?
For mild cases you usually start treatment with various topical medicines such as cortisone ointments, a vitamin D cream or retinoids, which are vitamin A derivatives.
For people with more advanced disease, therapy can include various types of light. The most popular phototherapy is called narrow-band UVB phototherapy, which is both very safe and well tolerated. There's also PUVA, which involves taking a pill first, then getting exposed to UVA light. And now we have been using light therapies that involve laser treatment, which is a UVB laser or vascular lesion lasers.
And then we get to the systemic therapies. Methotrexate, which is given either orally or as an injection, and cyclosporin, which is given orally. These medicines suppress the immune system. And now biologic therapy, a new development over the last two years, is available. Biologics are targeted therapies that affect the immune system. They are proteins that have various effects in the body and they have to be given by injection.
What factors go into making treatment decisions?
Moderate to severe psoriasis often requires systemic therapy. It is too difficult to treat with topical ointments and creams because it usually involves very large parts of the body. The various modes involve the phototherapy, which can be very effective, but difficult because patients have to come to the office a few times a week.
The methotrexate and the cyclosporin are therapies that have a lot of side effects. Methotrexate does affect the liver so people need liver biopsies after certain dosing, and cyclosporin does affect the blood pressure and the kidneys. So depending on the tolerance for risk, we may make a decision not to use one of these drugs.
The advantage of the new biologics is these side effects are very minimal. Biologics require some monitoring but they don't cause liver or kidney side effects. There are different types of biologics that are administered in different ways, which can affect someone's treatment plan. Sometimes a patient would prefer to give himself an injection at home. Other patients would prefer to have an injection at the office. These medications can also be combined with phototherapy or other medications.
Therapy with certain biologics often leads to period of time when no therapy is required. People may be going away on a summer vacation for three months, traveling, and don't want to have to give themselves injections. Many patients enjoy having this time away from their disease.
What do you consider a good response to these medications?
The response to biologics varies tremendously, anywhere from 90 percent clearing to as little as 10 to 20 percent. But many patients are very satisfied with a 50 percent reduction. Other patients feel that they need much better response; they're looking for 75 to 90 percent. A good response is mostly determined by the patients themselves. The results for the biologic agents seem to improve the longer the patient is receiving the medication, so biologics are most effective with long-term usage. People have less itching, they're comfortable, and they can wear clothes they like.
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