It's that time of year again when patients present with a flare of psoriasis. A chronic immune mediated condition which can affect both skin and joints, an estimated 7 million Americans are affected, making it the second most common skin disorder. Psoriasis is a genetic condition where there is a "short circuit" in the activity level of the immune system and ultimately affecting the way in which skin is produced. With sheer unpredictability, the immune system becomes "over active" and random sites begin to experience an increased rate of skin cell turn-over.

Skin forms thick white flaking plaques, often compared to the appearance of mica (hence the term micaceous flakes). Cracks, bleeding and discomfort accompany flare-ups. The elbows, knees, sacrum, scalp, nails, palms and soles are most commonly affected. However, nowhere is immune to the potential of developing psoriasis.

Psoriasis is not only disfiguring, it can destroy joints (psoriatic arthritis) and it can take an emotional toll. An equal opportunity skin disorder, men and women are equally affected. Children and infants are also potential victims and most at risk when battling a strep infection.

Flare factors include stress and illness; strep, mycoplasma and staph infections; lack of light exposure (hence the flare often experienced every fall and winter), hormonal imbalances (i.e. pregnancy), and sometimes for no reason at all.

From the Dead Sea to Tazorac, the search for the perfect, most effective psoriasis therapy has gone on for centuries. However, it was not until the last half of the twentieth century that major inroads into treatment were achieved.

The Dead Sea

The claims of this therapy have grown to mythic proportions. Thousands of psoriasis patients descend upon the Israeli Dead Sea psoriasis spas hoping for an improvement in their skin conditions. The combination of the Dead Sea mud, which contains up to ten times the amount of minerals and salts that other sources of mud do, the concentrated salinity of the water, and the hot, strong sun all combine to suppress the cellular turn over of psoriasis. This is sort of prehistoric Goekermann. Studies have refuted the therapeutic claims, but this has not had any apparent affect on the trade.

I have a feeling that the combination of the salt water's ability to soften the scales, the exfoliating and palliative nature of the mud and the sun exposure (UVA and UVB) combined with the serenity you would expect while on vacation (remember that stress is a major flare factor) do probably join to help improve psoriasis for many people on a temporary basis. For those looking for the benefits of treatment without a trip to the Middle East can now use AHAVA Bath Salts and AHAVA Dead Sea Mineral Mud which combine the mud and salts found in the Dead Sea. You don't have to have psoriasis to use AHAVA (demonstrated by it's recent huge popularity) but if you do, it wouldn't hurt to try to pamper yourself while treating your skin to some luxury.

Tar

Sometime in the 1800s, someone realized that tar had a healing effect upon the skin. It has been used for psoriasis, seborrhea, eczema and atopic dermatitis. What tar really does is help stop the cellular reproduction of the cells by interfering with mitosis (recall general biology?) However, tar smells, stains and is aesthetically rather unpleasing. In the 90's, tar has been reformulated by the big pharmaceutical houses to lose some of those displeasing qualities while staying effective. Balnetar Therapeutic Tar Bath remains a popular home choice for treating widespread body psoriasis. It is simply added to the bath water and you soak in it, allowing the tar to help slow down or stop the scale formation altogether as well as softening up those thickened crusts. Many a tar shampoo (look for the "T" in the name) is available. And DHS Tar Shampoo is by far the most popular DERMAdoctor psoriasis shampoo favorite. Remember if you are a blonde or have gray hair, that tar shampoos may cause some discoloration of the hair.

Tar and Light

Known as Goekermann, many a dermatology residency program became well known by what became a highly popular psoriasis therapy in the 30's. Basically patients bathed in a 5% coal tar solution (Zetar) and slept in it overnight. It was removed in the morning and they were treated with light therapy. The tar helped cut down on cellular turn over as well as attract the light better to the skin. Sort of pre-psoralen. This was still utilized up through the early 80's until medical insurance stepped in and began limiting hospitalizations. Then a series of out patient Goekermann centers arose. Goekermann is still available today, but is not as likely to be recommended as it once was. Maybe it's just me, but if I had the option to use anything but be covered in tar and zapped with light several times a week, I would try it first. Goekermann therapy deserves it's place in Dermatology hall of fame as it was one of the very first therapies to give positive results for a skin condition. Prior to that, there were minimal options for psoriasis.

Light Therapy

Along came a pill and made light therapy just ever so much easier and aesthetically pleasing to live through. Psoralen goes by the brand name Oxpsoralen Ultra. Downside: still going 2-3 times weekly, have to wear goggles for 24 hours when awake after taking the pill to protect the eyes, must protect the skin during that time frame as well (increases sunburn potential markedly) and light therapy has it's problems such as an increased risk of skin cancer development, sun burn, advancement of skin aging, cataracts, etc. Still, works terrifically and is well worth the aggravation for those with generalized large plaque psoriasis.

Topical Steroids

The introduction of steroids into the milieu of medical treatment options was heralded as nothing short of miraculous. Not only did it help treat and conquer more serious illness such as asthma, lupus, crippling arthritis and other autoimmune diseases, it was found to have usefulness for the treatment of multiple skin disorders. Topical steroids are one of the mainstays for psoriasis therapy. They diminish the inflammation, stop the itching, and help cut down on cellular proliferation. They are available as creams, ointments, lotions and liquids, so may be uniquely selected for use on various areas. Strengths range from OTC (1% is the highest here such as Cortaid and DERMAdoctor Handy Manum Medicated Skin Repair Serum with 1% Hydrocortisone. The latter is ideal for splits on the hands and feet as well as spotting onto scalp psoriasis when an rx option isn't available), up to the equivalent of topical prednisone in Temovate, the strongest topical steroid currently available by prescription.

The drawbacks to steroids are that overuse may lead to steroid atrophy (thinning of the skin) with associated stretch marks, blood vessels known as telangiectasis and even acne. Also, there are risks of developing pustular psoriasis (one of the few dermatologic emergencies) or addiction of the area. That is why the use of other agents such as Dovonex or Tazorac not only help improve clearing, they are steroid-sparing to the skin (meaning you can use far less steroid than you do when using it alone).

Systemic Steroids

Patient beware! Rebound, rebound, rebound! The risk of rebound phenomenon (the rash returns worse once the steroid is gone from the system) and the potential to develop pustular psorasis not to mention the systemic problems ranging from diabetes, high blood pressure, osteoporosis, "mood swings" are all good reasons to avoid this if at all possible. I usually reserve this therapy for psoriasis patients who have what is known as exfoliative erythroderma. In this condition, usually 100% of their body has turned bright red and the skin is peeling off. Often bordering on a dermatologic emergency, systemic steroids (whether oral or IV) provide rapid imrpovement. However, these patients usually then require prolonged tapering on oral steroids to prevent a rebound reaction. I avoid injectable steroids whenever possible as everyone's system absorbs them at a different rate and it is impossible to control the dosing availability at any given time.

Anti-Yeast Preps

What a surprise to learn early on that the normal yeast and bacteria that live on our skin can actually flare both psoriasis and seborrhea, particularly in hair bearing areas such as the face and scalp. I always include this therapy now for psoriasis patients who experience eruptions in these regions and it makes a big difference. While I have been most impressed with Nizoral Cream for the face, bear in mind that it occasionally is irritating to already sore, sensitive skin. Nizoral quickly underwent morphing into shampoo (Nizoral A-D Shampoo) and is very helpful for treating scalp psoriasis or for washing the face especially for men with facial hair. Carmol Deep Cleansing Antibacterial Shampoo and prescription Loprox Shampoo also help reduce yeast and bacterial counts on the scalp which in turn helps reign in control over psoriasis.

The use of a solitary dandruff shampoo is usually not enough to treat either psoriasis or seborrheic dermatitis, but when combined into a regimen which takes advantage of other active ingredients to target the psoriatic pathway, it is amazing how helpful it is when used in combination with other agents in your regimen.

Antiyeast creams are also used in the treatment of psoriasis when the face is affected. Redness, scale and crusts can form in the eyebrows, nasolabial folds extending between the nose and angles of the mouth (smile lines) and "beard" distribution. Known as sebopsoriasis, the use of topical DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream, prescription Nizoral Cream or other anti-yeast cream can help round out treatment for the same reasons that dandruff shampoos make use of these yeast-killing ingredients.

There is an unusual presentation of psorasis called Napkin Dermatitis aka Inverse or Atypical Psoriasis. It arises in moist regions such as under the breasts, between the legs or under heavy abdominal folds. Most nondermatologists (and some dermatologists as well) mistake it for a fungal infection and do not understand why it will not go away. It is actually psorasis. In these areas, a mild topical steroid (as the area is what is called "under occlusion" from the heavy skin fold which drives the steroid deeper in to the skin and can cause a higher rate of atrophy) and nizoral cream can really help. For really moist areas, the use of Rx Mycostatin Powder or non-RX Zeasorb-AF Antifungal Powder powder can really help dry out the area. Do not use corn starch based powders as they act as food for yeast and bacteria.

Zinc Pyrithione

Zinc pyrithione has long been known to help control dandruff flare-ups. The reason seems to be that it makes the skin surface environment inhospitable to normal yeast that inhabit the area and drive psoriasis as well as seborrheic dermatitis. Zinc pyrithione is available in several options including shampoos like DHS Zinc Shampoo, creams like DermaZinc Cream and sprays such as DermaZinc - Advanced Formula Zinc Therapy Spray/Drops. The cream may be used on areas of psoriasis like the face and body. The spray is an excellent option to incorporate into a routine for targeting psoriasis affecting the scalp.

Qusamine-ST with Releven

Qusamine-ST with Releven is an innovative cream designed to relieve the itch associated with psoriasis. Qusamine-ST contains Releven, a balanced combination of salicylic acid along with amino acids and amino sugars designed to relieve the itch associated with psoriasis. Releven is believed to help reduce the formation of 3-deoxyglucosone (3DG), a by-product of the body's biochemistry and a contributor to psoriasis itch. This product is steroid-free, fragrance-free and paraben-free.

Antibiotics

Anyone who has ever experienced strep throat and has psoriasis may have found themselves covered with literally thousands of small psoriatic plaques. Called Guttate Psoriasis, it looks much like many water droplets that were flicked at the skin. These are typically seen in association with bacterial infections, so oral antibiotics are often given when this type of psoriasis is seen. The body is a truly amazing thing. I still remember the adult who had ongoing awful psorasis, usually guttate due to chronic tonsilitis. She finally had her tonsils out and then promptly cleared. Tonsiectomies are not routine procedures ordered by dermatologists, but it was a very impressive cure.

Keratolytics

Agents used to soften and exfoliate the thickened psoriatic scales are often incorporated into therapy. While they do not address the underlying problems that cause psoriasis, thinning and smoothing out thickened, often cracking skin can palliate discomfort as well as improve the overall skin aesthetics. From bland creams and ointments, (such as Vanicream or Nouriva) to those with "active" ingredients that help exfoliate scales, such as prescription LacHydrin (12% lactic acid), Carmol 10 Lotion or Carmol 20 Cream (contain urea), Priori Advanced AHA Hand & Body Revitalizing Lotion (contains lactic acid) or DERMAdoctor KP Duty Dermatologist Moisturizing Therapy For Dry Skin (which contains urea and glycolic acid), there are many options to try.

Apply a hydrating agent immediately after bathing, washing your hands (if that area is affected) to protect the skin from the environment and from drying out. Also, make sure you keep your psorasis meds on hand. The topicals are going to hydrate the skin in addition to helping to actively treat the psoriasis, so starting them early can really make a difference.

Nails

Psoriasis of the nails is always much easier to identify if there are psoriatic plaques elsewhere on the body. Otherwise, problems such as fungal infections of the nails and lichen planus of the nails can mimic the condition. Therapy is pretty limited, particularly for a child. The reason is that topicals just do not penetrate down into the nail fold where the psoriasis is actually disfiguring the nail plate, and those big gun oral therapies that would correct the situation are not typically appropriate for use simply for nail psoriasis, especially for young children (such as chemotherapy agents like Methotrexate, etc.)

If you are familiar with those spray jet vaccinations that were popular in schools in the 1960's (they had the advantage of rapidly treating numerous children without having to fuss with needles), this procedure has been used to inject steroid solution (kenalog) into the nail fold. The drawbacks are that it is not a cure, although with multiple treatments it does help and can be used on a maintenance basis, and it really hurts. If you are highly motivated and able to tolerate pain fairly well, it may be worth considering.

Another option would be to try to use both Dovonex Solution and Temovate or Cormax Solutions that are able to get under the nail fold and apply a few drops twice daily. Again, topicals are not that great at working, but it is something to try. Be alert to steroid atrophy of the cuticle area!

Topical local PUVA would be a final option. Many dermatologists do not like performing PUVA on children as cummulative light therapy damage early in life can increase the risk of developing skin cancer later on. There is a new form of PUVA called narrow band that has less risks associated with it. You may want to inquire in your locale.

Scalp

The different products have different modes of intervention in treating psoriasis, so that is why interrupting the physiology of the condition at multiple points is more successful. Nizoral 2% (prescription strength) shampoo works because it reduces the amounts of bacteria and yeast that live on our skin, stimulating the seborrhea. Using this shampoo twice weekly is highly effective WHEN COMBINED WITH OTHER TREATMENT. There aren't too many of my patients who ever responded to it alone - you need something to bolster it's actions. There is now an OTC strength version of this shampoo called Nizoral A-D Shampoo which contains 1% of the active ingredient, ketoconazole.

Capex, a prescription steroid-based shampoo, formerly known as FS shampoo, is also something I combine into a patient's regimen. The steroid helps diminish the inflammation that accompanies the process. I usually have an individual shampoo daily for one week with the Capex Shampoo, and then use it 1-2 times a week thereafter, using their prescription Nizoral shampoo, and even their DHS shampoo on different days. To help cut through thicker scale, DermaSmoothe FS may be applied to the scalp at night and washed out in the morning. I typically do not use this for more than a week at a time, and may alternate it with the P&S Liquid to increase the attack on thicker scale.

Newer shampoos containing AHAs like glycolic acid contained in Aqua Glycolic Shampoo & Body Cleanser can also help remove excess scale on the scalp. Another product line, P&S which includes P&S Liquid which I like incorporating into the regimen of scalp psoriasis patients as it really cuts through very thick scale.

Many times, particularly at the height of the flare, topical prescription steroid drops are needed. Packaged in "Visine-like" bottles, just 5-8 drops are randomly scattered on the scalp twice a day when the shampoos aren't enough to control the condition. When the scalp is clear, the drops are shelved until the next bout. These steroid solutions vary widely in their strength, and I select one based upon the severity of the condition. For over-the-counter fixes, DERMAdoctor Handy Manum Medicated Skin Repair Serum with 1% Hydrocortisone can help. It can provide some relief for milder cases of dandruff or when you can't get in to see the doctor.

Dovonex

Dovonex represented a turning point in the fight against psoriasis and a new hope for dermatologists. Up until that point, there had been nothing new for more than a decade. Dovonex is a vitamin D3 derivative that helps normalize cellular turn over. I have found Dovonex to be helpful yet often requiring the co-administration of other medications such as topical steroids. It does not tend to be irritating, has been widely accepted and is an excellent option to consider particularly for scalp psoriasis as it is now available in a liquid formulation. I like liquids for the scalp. I base treatment on what I would like. The thought of rubbing in ointments into my hair doesn't thrill me, so the option for clear liquids is great.

Topical Vitamin A (Tazorac)

In my opinion, this is one of the best therapy modalities for psoriasis. I have been amazed by the effectiveness of Tazorac for the treatment of psoriasis. In fact, I did not have a single patient failure with this product. However, I use it differently than recommended by the manufacturer. I use it just the way I have learned that other topical vitamin A creams are best tolerated-every other night, very sparingly, on very dry skin. Every morning, I have the patient apply Temovate to the area (with the exceptions being face, groin, flexures, neck, or on children).

Within 4-6 weeks, clearing is seen. For stubborn areas, we then increase the use of the Tazorac to every night if tolerated. I go straight to the stronger 0.1% gel unless the affected areas are those same thin regions I avoid the use of Temovate on. This has been one of the most impressive therapies I have ever come across, and I mean it. Having participated in 2 of the studies, Tazorac is a superior psorasis medication for large plaque therapy. Certainly if someone is affected by generalized psoriasis, napkin dermatitis (atypical psoriasis) or pustular psorasis, this may not be appropriate. Ask your dermatologist if this therapy would be right for you.

THE BIG GUNS OF THERAPY

Hydroxyurea

A chemotherapy medication used as a very old fashioned therapy for the treatment of severe psoriasis, prior to the availability of newer systemic therapies. Currently it is not widely used for psoriasis, however, it may offer therapeutic options for those with significant psoriasis who for some reason are not able to tolerate more current therapy.

Allopurinol

Allopurinol is best known for the treatment of gout. It basically stops the cellular mitosis (which in gout ultimately prevents the formation of urea crystals that cause gout in the joints). Too much may cause GI disturbances such as diarrhea. This is also not as widely used with so many newer medications specifically for the treatment of severe psoriasis.

Oral Vitamin A Preps

Accutane, Tegison, Soriatane

Accutane (generic Isotretinoin), the first prescription oral Vitamin A derivative for the treatment of severe cystic acne, was found to help normalize the keratinization problems seen with severe psoriasis. It was at times used in conjunction with light therapy. Newer variations included Tegison (generic name Etretinate) which has since been taken off the market with the advent of Soriatane (generic Acetretin). One of the biggest differences between Tegison and Soriatane was due to birth defect issues. All 3 medications cause birth defects if a pregnancy occurs while on medication. However, the time span was vastly different. With Accutane, it is safe to conceive after 30 days of discontinuing the product. Soriatane has a 3 year span while Tegison stayed in the system indefinitely, making a safe pregnancy impossible. Accutane is not nearly as effective as Soriatane for psoriasis, which is why it is not a typical substitute when an oral vitamin A derivate is required. Neither is used unless there is overwhelming exfoliative erythroderic or pustular forms of psoriasis.

Blood work is done every few weeks to monitor blood counts, liver enzymes and general chemistry. Two methods of contraception are required during treatment and during the post medication time frame specific to each drug. Blood donation is not allowed during these phases due to the risk to the blood recipient.

Alcohol is specifically not allowed while taking Soriatane as it can cause the drug to be broken down into Tegison.

Methotrexate

Methotrexate (abbreviated MTX), made me the mini psorasis guru for a time when I was first out of residency. (I received my first thank you gift basket when I gave a patient with generalized psoriasis MTX.) It had been difficult to convince her to try it, but within a month, she was clear for the first time in years. I think this made a big impression on both of us as to why aggressive, well thought out therapy is so very important to patients. Clear skin can be the holy grail for some, and it has been extremely rewarding for me through the years to attain this for so many patients.

Methotrexate is given as 3 oral doses 12 hours apart just once a week. The number of pills used for each therapy is how we describe it's use. For instance, 1:1:1 refers to a patient taking just 1 pill every 12 hours for 3 doses. However, 2:1:1 refers to 2 pills taken as the first dose, then 1 pill for each of the remaining 2 doses. This allows the dermatologist to very closely titrate the correct amount required for each individual patient. Methotrexate is a big gun medication associated with several side effects. Its primary use is as a chemotherapy medication. However, the above once weekly low dose regimen rarely affects the psoriasis patient with hair loss, nausea, vomiting, etc.

It required frequent monitoring of the blood counts and liver enzymes by blood work and annual liver biopsies when the drug is used on a long term basis. While still used widely, there are now other more recent therapies that are cutting into its use.

Cytoxan

This is another very serious medication that I have typically reserved for the use of significant psoriatic vasculitis associated with psoriatic arthritis. What this means is that in rare instances, the destructive nature of the associated psoriatic arthritis becomes focused upon the blood vessels and can cause significant ulceration of the skin. This is a major complication requiring immediate and aggressive therapy, often in a hospital setting. Cytoxan in pill form is known to be used for other autoimmune diseases not responsive to more common therapies. In IV form, it is a chemotherapy drug.

Cyclosporin/Neoral

Used initially for preventing the rejection of transplanted organs, Cyclosporin has been found to be very helpful in many overwhelming skin conditions including generalized exfoliative psoriasis. Main draw backs., frequent monitoring, potential kidney damage (less likely with the lower dosing used for skin conditions as opposed to transplant patients) and the low potential to develop lymphoma. Most psoriasis patients will never come across this drug as a therapeutic option.

Laser

The FDA has approved the first laser for the treatment of resistant plaque form of psoriasis. Called the XTRAC excimer laser made by PhotoMedex, uses a specially focused beam of light and approximately 4-10 treatments are required to clear the unsightly, often painful plaques. Sessions take just a few minutes and do not require any form of anesthesia. During the laser treatment series, topical psoriasis medications are not necessary. Two treatments are performed weekly and often the patient will notice some improvement within just a few sessions. This treatment focuses treatment directly upon stubborn psoriatic plaques instead of zapping the entire body with light as is done with PUVA. This has good potential, but is not widely available yet. At this time, medical insurance does not usually cover the laser treatments and you can expect to pay anywhere from $150.00 and up per treatment.

Biologic Agents

The newest arena of psoriasis therapy are the biologics. These drugs, administered intravenously or by injection block the abnormal immune system responses believed to cause the condition. Approximately 1.35 million Americans suffer a severe enough case of psoriasis to warrant the use of this class of drugs. This is basically 30% of the 4.5 million U.S. psoriasis patients. Research has shown that the activation of T-cells, a type of white blood cell, is the key point to trigger the immune system in the development of psoriasis. Once the T cells are activated, they release a group of chemicals known as cytokines. Cytokines function as immune system messengers. In psoriasis, the cytokines communicate to epidermal cells that they should reproduce at an abnormally fast rate. Biologics try to block the T-cell activation or the release of the cytokines.

Currently Amevive (generic name is alefacept), is the only drug FDA approved for the psoriasis treatment on the market. It has a 20% rate of effectiveness (1 in 5 patients improve). The drug is administered intravenously for 12 weeks and patients continue to remain clear for about 8 months after completion of the therapy. Amevive works by destroying activated T-cells.

A second biologic that is FDA approved for the treatment of psoriatic arthritis but does not yet carry the indication for the treatment of psoriasis is Enbrel (generic name etanercept). Enbrel blocks the cytokine TNF (stands for tumor necrosis factor) from telling the epidermal skin cells to over-reproduce. Studies show that Enbrel given twice a week by subcutaneous injection cleared 70% of patients of at least 50% of their psoriatic plaques. Another distinguishing factor is that the patient at home can administer Enbrel, unlike intravenous Amevive.

Raptiva (generic name is efalizumab) is made by Genentech and Xoma. This drug is still in testing. Raptiva is a humanized monoclonal antibody, which essentially neutralizes the T-cell's ability to function and communicate with other cells. Given by injection over 3 months, 59 percent of patients saw a reduction of their plaques by 50%.

Remicade (generic name is infliximab) is currently on the market for Crohn's disease and rheumatoid arthritis. It is also a monoclonal antibody but binds with TNF alpha (tumor necrosis factor alpha) and prevents this cytokine from functioning. Remicade is given intravenously (at least for its currently FDA approved uses). At the 2003 AAD, Remicade was reported to have improved 88 percent of patients with a 75% reduction of clinical symptoms.

Biologics don't come cheap. A year's worth of treatment can run than $10,000 a year. Medical insurance is expected to cover much of the cost of these therapies.

Psoriasis therapy has never seen so many new options in an entirely new category of treatment. This is great news to dermatologists and wonderful news for psoriasis patients everywhere.

Psoriasis does have many wonderful therapies, many new in the past 5-10 years. While there is still no cure, almost everyone has the potential to clear stubborn plaques. If you suffer from psoriasis and have not yet seen a dermatologist, I would urge you to do so. These days there is no reason to have to allow it to go unchecked.

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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