Treatment Of Psoriasis: Therapies And Contraindications

Since there is still no definitive cure, psoriasis treatment is aimed at controlling the disease and symptoms.
Psoriasis treatment: therapies and contraindications

Treatment of psoriasis is symptomatic and depends on the patient’s clinical situation. Therefore, there is no definitive cure, but several treatments for the control of the disease and symptoms. Among these we find:

  • Inflammation.
  • Redness.
  • Desquamation.
  • Burning.

Psoriasis treatments consist of:

  • Topical therapies.
  • Phototherapy and photo chemotherapy.
  • Oral systemic drugs.
  • Biological therapies.

Treatment of psoriasis

Topical therapies

These are initial treatments, which apply to most patients. They consist in the application of creams and lotions on skin lesions.     

Among the most used topical drugs for psoriasis, we remember:

  • Vitamin D analogues.
  • Topical corticosteroids.
  • Keratolytics.
  • Topical retinoids.
  • Coal tar.

Vitamin D analogues: calcitriol, calcipotriol or tacalcitol

The most effective is  calcipotriol. The clinical response of this vitamin D analogue is slower than that offered by high potency corticoids. However, it is safer, making it ideal for long-term treatment. 

It is recommended to use it in conjunction with a topical corticosteroid, as this combination is more effective than any vitamin D analog taken alone.

Despite being very safe, vitamin D analogues have a rather important side effect. They can, in fact, irritate the skin already damaged, so you must avoid exposure to sunlight after applying them.

Topical corticosteroids

This group of medicines works mainly by clearing plaques and reducing inflammation. Low-power ones are used for the most delicate areas (face and folds) and the most powerful ones for the scalp, larger plaques, hands and feet.

Corticosteroids for the treatment of psoriasis

At the beginning it is recommended to apply the high power ones and then continue with the more delicate ones. It is also useful to associate them with other therapies, such as vitamin D analogues.
However, care must be taken with this category of drugs, as they have topical and systemic side effects.  
Among the local effects we find, for example:

  • Thinning of the epidermis.
  • Lightening of the skin due to the inhibition of melanocytes.
  • Acne rosacea.
  • Purple.

Systemic effects are infrequent but severe. These include inhibition of the hypothalamic-pituitary axis and Cushing’s syndrome.

To avoid such side effects, a maximum of two applications per day is recommended, taking into account the rebound effect  if treatment is suddenly stopped.

Keratolytics: acetylsalicylic acid (aspirin)

Acetylsalicylic acid is limited only to eliminating scaly plaques; promotes tissue renewal and enhances the efficacy of associated medicines, facilitating their absorption. It is therefore a complementary treatment.   

Topical retinoids

They are the analogues of vitamin A.  Tazarotene is, for the moment, the only one available for the treatment of psoriasis and is used together with corticosteroids.  

As it can cause skin irritation, use on the face and folds should be avoided. Like all analogues of vitamin A, it is photosensitive and teratogenic, therefore it is contraindicated for pregnant women. 

Coal tar

It is the oldest treatment for psoriasis. These coal tar preparations are applied to skin folds,  even if their smell is unpleasant and easily stains clothes.

They are photosensitive, so exposure to the sun must be avoided after applying them.  

Phototherapy and photo chemotherapy

It is used when the patient does not respond adequately to topical therapies or when the lesions are very extensive. 

  • Phototherapy: these are UVB rays (narrow band ones are more effective and cause less burns). It is associated with tazarotene, vitamin D analogues or systemic treatments.
  • Photochemotherapy: Also known as PUVA. It consists of the combination of UVA radiation after topical or oral administration of a psoralen that acts as a photo-sensitizer. Its use is alternative in patients in whom UVBs do not give results. PUVA, in fact, has greater efficacy and a longer lasting effect, although it is associated with basalioma (basal cell carcinoma) and melanoma.
Photochemotherapy for the treatment of psoriasis

Oral systemic drugs

Systemic treatment is indicated in case of failure to respond to other therapies. It is based on the administration of:

  • Immunosuppressants
  • Retinoids

Immunosuppressants

Among these drugs, the most used is methotrexate, especially in long-term treatments. The patient must be monitored constantly, due to the severe side effects. Pregnancy should be avoided for up to 3 months following treatment.

Among these drugs, oral cyclosporine is often used. It has a similar or even superior efficacy to metatrexate, but is nephrotoxic and causes hypertension. It therefore requires constant observation of the patient.

It is recommended for short-term treatments.

Retinoids

Acitretin, an analogue of vitamin A, can be considered an alternative for patients suffering from pustular psoriasis and immunosuppression and therefore cannot take immunosuppressive drugs.  

It can be combined with UVB or PUVA, but is less effective than cyclosporine. It also preserves its teratogenesis for up to 2 years after treatment.

Biological therapies for the treatment of psoriasis

They are intended for people who cannot access other treatments, who are intolerant to PUVA and systemic oral treatments.

Ustekinumab is a specific biologic drug for psoriasis. Requires constant observation for side effects control as long-term effects are not known.

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