Using Treatment Regimens That Minimize Side Effects
In order to reduce side effects for long-term use of topical corticosteroids, a number of new therapy regimens have been studied. One of them is weekend or pulse therapy where three consecutive doses of corticosteroids at 12h intervals are given on the weekends, following a successful initial cleared or almost cleared therapeutic response to daily potent topical corticosteroids application .
Topical Tazarotene And Corticosteroids
Tazarotene was the first topic retinoid found to be effective for mild-to-moderate psoriasis and it is available in cream or gel form.
Tazarotene is a retinoid derivate which binds the retinoic acid receptor in a class-specific manner, preferentially binding RAR- and RAR- than RAR- . This regulation of transcription result in reduced keratinocyte proliferation, normalized keratinocyte differentiation, and decreased inflammation. Its protective role against cutaneous atrophy from corticosteroid induction, may be important already shown by the retinoid tretinoin .
This retinoid may cause skin irritation in up to 30% of users , and this irritation was more pronounced in patients receiving tazarotene plus corticosteroids than in those receiving calcipotriol .
Retinoids may reduce UVB tolerance, and tazarotene has proven to be more efficacious than UVB alone .
As the systemic retinoids, tazarotene is contraindicated in pregnancy.
It is not indicated to prescribe tazarotene mixed with corticosteroids. Although tazarotene showed to be chemically compatible with a number of topical corticosteroids, no experiment testing over two weeks of treatment has been performed .
What Is Psoriasis Symptoms Causes Diagnosis Treatment And Prevention
Psoriasis is an autoimmune disease that causes plaques, which are itchy or sore patches of thick, dry, discolored skin.
While any part of your body can be affected, psoriasis plaques most often develop on the elbows, knees, scalp, back, face, palms, and feet.
Like other autoinflammatory diseases, psoriasis occurs when your immune system which normally attacks infectious germs begins to attack healthy cells instead.
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Intervention Group: Detailed Description Of The Improved Patient
The intervention group will include support delivered by three experienced dermatology nurses . Each patient will be supported by the same dermatology nurse throughout the entire study period. The intervention is expected to encourage psoriasis patients to apply the topical drugs on a regular basis by 1) ensuring that patients have a reminder system , 2) making patients accountable , 3) providing support , 4) building trust in the treatment and healthcare-provider , and 5) by increasing perceived ease of use via favorable comparisons to other treatment options . Participants in the intervention group will be seen by a nurse in the dermatology clinic at baseline and weeks 12, 24, 36, and 48 . Furthermore, the participants will either be seen in the dermatology clinic or receive follow-up from the nurse by telephone at weeks 1, 4, 8, 16, 20, 28, 32, 40, and 44.
Table 1 Guide for the patient-supporting consultations. The examples of questions or sentences will be modified by the nurse according to the patients needs at the time of the consultation
Following Recommendations Of Usage
The topical corticosteroid recommendations suggest, for the most corticosteroids, 60g, as a maximum dosage per week, and for some superpotent corticosteroids 50g per week. However, there are particularly cases in which patients need to exceed what the package insert recommends, and in those circumstances the possibility of systemic absorption must be considered.
For thick areas that are more resistant to steroid side effects such as the palms and soles, limited occlusion may be necessary and would require close followup, but for more prone areas such as the axillae, groin, and face, occlusion is more probable to result in adverse effects .
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Topical Salicylic Acid And Corticosteroids
Salicylic acid is a topical keratolytic used in the treatment of a variety of papulosquamous lesions such as psoriasis. Its mechanism of action is still unclear, but it is believed to act by inducing disruption of keratinocyte-keratinocyte binding and softening of the stratum corneum by decreasing its pH .
Salicylic acid has a filtering effect reducing the efficacy of UVB therapy, so it should not be applied before treatment. Due to scarce data, it should not be applied during pregnancy .
Usually, salicylic acid is safe however, with long-term use in large skin areas, systemic salicylic acid toxicity can occur .
Studies with tritiated triamcinolone acetonide, desoximetasone, and hydrocortisone 17-valerate showed that salicylic acid enhance the efficacy of these corticosteroids by increasing their penetration in skin. This faster penetration of corticosteroids in skin does not occur when mixed with other ingredients such as camphor, menthol, phenol, or urea.
Fixed-dose combinations such as salicylic acid and betamethasone propionate or salicylic acid with diflucortolone are already available in some countries and they show similar efficacy. They both appear to be efficacious and well tolerated during short-term period treatment of plaque psoriasis and their use is recommended for limited areas of skin: for thick, scaly, and psoriatic plaques .
How Is Cyclosporine Used
Cyclosporine is taken daily by mouth in capsule or liquid form. The liquid form must be diluted for use, preferably mixed at room temperature with orange or apple juice. Do not mix with grapefruit juice. Cyclosporine must be taken on a consistent schedule.
Cyclosporine is most often used for recalcitrant psoriasis that does not respond to other systemic treatments.
Cyclosporine can provide rapid relief from symptoms. You may see some improvement in symptoms after two weeks of treatment, particularly with stronger doses. However, it may take from three to four months to reach optimal control.
Extended use of cyclosporine by transplant patients is well-established. However, long-term use as a treatment for psoriasis is more limited. The FDA recommends cyclosporine not be used for longer than one year. However, there are no specific guidelines for how long you should stay off cyclosporine before resuming treatment. Some doctors may prescribe the drug for more than one year.
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New Combination Treatment Of Topical Corticosteroids
Combination therapy has emerged with the development of new noncorticosteroid preparations, but before the merge we have to make sure that the two combinations are compatible, synergistic, and safe. As an example, calcipotriol is just compatible with tar gel and halobetasol propionate preparations and it has a superior effect when combined with halobetasol ointment. Halobetasol decreased the irritant dermatitis caused by calcipotriol . Also ammonium lactate is compatible with hydrocortisone valerate and halobetasol propionate, and it has been shown to protect against skin atrophy .
Salicylic acid, vitamin D analogues and retinoids, with different mechanisms of action, are usually combined with topical corticosteroids. Concerning polytherapy versus fixed-dose combinations, the last one requires less frequent applications and has a higher adherence from the patients.
Before Stopping Psoriasis Treatment Talk With Your Dermatologist
Because psoriasis is a lifelong disease, its understandable that you may want to stop treatment at some point. Alwaystalk with your dermatologist before you stop treatment.
Some treatments can be stopped immediately. Others need to be discontinued slowly to prevent psoriasis from worsening .
When psoriasis rebounds, it may become a more serious type of psoriasis. A person who had plaque psoriasis may suddenly have pustular psoriasis or erythrodermic psoriasis.
The best way to prevent a rebound is to talk with your dermatologist. Your dermatologist can tell you whether you can stop the treatment abruptly or slowly. Sometimes, the best approach is to gradually switch to another treatment.
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Things To Keep In Mind When Using A Topical Steroid:
- Apply a small amount of the steroid on the affected areas only.
- Donât use a topical steroid for longer than three weeks without consulting your health care provider.
- Refrain from abruptly discontinuing a topical steroid as it can cause your psoriasis to flare.
- Unless the medication is formulated for the eye area, do not use steroids on, in or around the eyes, as cataracts and glaucoma can result.
- The more potent the steroid, the more effective it is in clearing psoriasis, but the risk of side effects is greater.
- Low-strength steroids are good for treating the face, groin and breasts, but care must be taken as the risk of side effects is greater in sensitive skin areas.
Potential side effects of topical steroids include skin damage, such as skin thinning, changes in pigmentation, easy bruising, stretch marks, redness and dilated surface blood vessels. Steroids can be absorbed through the skin and affect internal organs when applied to widespread areas of skin, used over long periods of time, or used with excessive occlusion.
Have more questions about whether a topical treatment is for you? Your health care provider can provide you with more information related to these treatments, and discuss if they are a fit for your treatment plan. Please speak with your health care provider about the use of topical steroid treatments on children affected by psoriasis.
How Is Psoriasis Diagnosed
A doctor can diagnose psoriasis by examining the skin, scalp, and nails for signs of the condition.
They may also ask questions to determine if a person has experienced any symptoms of psoriasis, or has a family history of the disorder. Its possible that they may also take a biopsy of the skin to examine it more closely.
There are various treatments that may improve symptoms of psoriasis. A dermatologist can advise you on the best options for a person, depending on where the rashes are on the body and the severity of the condition.
Treatments may include both prescription and over-the-counter medications, phototherapy, and diet.
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Short & Long Term Complications
Arthritis Up to 30% of people who have Psoriasis also develop Psoriasis Arthritis later on in their life, usually in their senior years when normal arthritis begins to occur. Psoriasis Arthritis is the swelling of joints as well as the skin, and can cause pain in joints all over your body from your fingers to your spine. Most common side effects are joint pain, stiffness and swelling.
Cardiovascular disease New researches say that Psoriasis and Heart diseases are linked, and that people who have Psoriasis are more likely to have heart attacks or other heart disease related side affects. The cause of what Psoriasis has to do with Cardiovascular disease is still undergoing extensive studies.
Psychosocial disorders Psoriasis, along with other chronic diseases can have a large impact on the emotional wellness of people who have it. It could impact the persons relationships, self-image, which can cause symptoms such as depression. Severe Psoriasis can also cause discomfort in the body and make it a disabling disease if motion is affected, and one becomes unable to work as a result.
New Strategies To Improve Safety Of Topical Corticosteroids
Taking into account one of the most important features of psoriasis, its chronic nature, the therapeutic approach should be prolonged, which makes it challenging to use high-potency topical corticosteroids safely in long-term management of the disease .
Therefore, therapy should be monitored by a competent healthcare professional to limit the risk of cutaneous or systemic side effects, and some general principles should be followed to minimize these effects . The untoward effects of topical corticosteroids have been well documented and can be widely categorized as local or systemic .
Strategies to improve safety for long-term use of topical corticosteroids in psoriasis.
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Psoriasis: More Than Skin Deep
The first accurate medical discussion of psoriasis dates back to 1801, but the disease itself is much older. In fact, its very name is borrowed from an ancient Greek word meaning an itchy or scaly condition. About 7 million Americans are plagued by this itching and scaling, and many of them have serious complications involving other organs. Although psoriasis is classified as a dermatologic disease, it doesn’t start in the skin, and its damage may be more than skin deep.
Are There Any Side Effects Of Psoriasis Medication Treatment
Psoriasis is a well-known condition. This ubiquity has granted this disease a fair amount of research from dermatologists. Consequently, these researchers have come up with a veritable smorgasbord of treatments. These treatments, while many in number, and effective in their application, are not fully without risks. The side effects at a time tend to outweigh the rewards of its effectiveness. These medications and their side effects include the following:
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Amount Of Support From Each Donor
Payments from LEO Foundation: 2,200,000 DKK. Payments from Odense University Hospital Free Research Fund: 100,000 DKK. Payments from Robert Wehnerts and Kirsten Wehnerts Foundation: 25,000 DKK. Payments from the Psoriasis Research Foundation: 125,000 DKK. Payments from Jeweler A.L. Rasmussens Memorial Foundation: 20,000 DKK.
Funding will be used solely for paying research staff and covering expenses for the trial during the trial period. There will be no payments to trial participants. Participants will, however, receive a minor gift at week 24, as a reward . Providing participants with a small gift meets the requirements of the National Committee on Health Research Ethics, since the small gift will be given after consent has been signed and participants will not be aware of the opportunity to receive a gift at the time, they sign the consent form.
The funding body will not have any influence on the design of the study or the collection, analysis, and interpretation of data or on writing the manuscript.
Let’s Talk Risk Factors
Because of the key role that the immune system plays in the defense against cancer in the body, there has been concern about the risk of cancer with treatment with biologics. In particular, there is worry that by inhibiting tumor necrosis factor , you may be stopping the natural action of this compound to stop cancers.
TNF was named before its full role was completely understood. TNF actually has multiple functions and is well-known as a promoter of inflammation and is actively involved in the pathogenesis of many autoimmune diseases. Chronic inflammation by itself can increase the likelihood of cancer.
Another activity of TNF is its effect on angiogenesis, which is the development of new blood vessels an activity that is critical for tumor growth, survival, and metastasis . Some researchers believe that the use of TNF inhibitors may actually decrease the risk of some cancers, by reducing angiogenesis and suppressing inflammation.4
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Signs And Symptoms Of Psoriasis
Psoriasis plaques can range from a few spots of dandruff-like scaling to major eruptions that cover large areas. The diseases symptoms and appearance vary according to the type and severity of psoriasis.
Some common signs and symptoms include:
- Discolored patches or raised plaques of skin that are covered with scales
- Burning, itching, or soreness near the affected areas
- Pitted or thickened fingernails or toenails
What Are The Risks
Individuals previously treated with methotrexate or other immunosuppressive agents, PUVA, UVB, coal tar, or radiation therapy are at an increased risk of developing skin cancer when taking cyclosporine. Additional risks with cyclosporine include kidney damage. This increases with length of time and the amount of cyclosporine taken. Your health care provider will monitor your kidney function before and during treatment. Patients can also develop hypertension on this medication, so frequent blood pressure checks are important.
Vaccinations may be less effective if taken while on cyclosporine. Talk to your health care provider if you plan to get any kind of vaccination.
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Is It Scalp Psoriasis Or Dandruff
More than half of all psoriasis patients have scalp psoriasis, according to the NPF. Itchy plaques can extend beyond the hairline onto the forehead, neck, and around the ears.
“Most people with scalp psoriasis have it on other parts of their body as well,” says Dina D. Strachan, MD, a dermatologist and assistant clinical professor of dermatology at NYU Langone Medical Center in New York City.
Scalp psoriasis is sometimes confused with seborrheic dermatitis, or dandruff. According to Dr. Strachan, dandruff which causes a flaky, itchy scalp without signs of inflammation tends to itch more than scalp psoriasis. It has a greasy-appearing yellow scale, Strachan says. In contrast, psoriasis whether it’s on your scalp or any other body part tends to have a thick, silvery scale.”
Who Will Take The Informed Consent
The investigators first contact with potential participants will take place in an individual face-to-face consultation prior to the baseline visit. Prior to presenting information about the study, the investigator will inform potential participants of their right to make another appointment at which a companion can be present. Potential participants will be provided with oral and written information about the study. The consent will also grant the authorities the right to monitor and check the patients trial-related data obtained in the electronic research data capture and from the patients medical chart .
If the patient has decided to participate in the study, the patient in question will date and sign the informed consent and deliver it personally to the investigator. The informed consent is then to be dated and signed by the attesting investigator on the day the patient is informed. The original consent form will be stored in the patients case report form .
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Considering Use In Vulnerable Areas
The face and the intertriginous areas are particularly sensitive to untoward effects. For that reason, the protracted use of corticosteroids, even with lower potency, can be associated with telangiectasia on the face and formation of striae on intertriginous sites such as the groin, axillae, or under the breasts .
Even though safety of topical corticosteroids and other topical treatments has been recently reviewed, additional studies of topical corticosteroids are imperative.
Specific Ethical Considerations In The Study
All participants will be informed that the purpose of the study is to investigate how psoriasis improves with topical drugs used in a real-life setting. The study will be performed in accordance with the ethical principles in the Helsinki Declaration .
Participation in the study will not expose participants to more risk of side-effects than receiving standard of care treatment.
Topical corticosteroids and calcipotriol are safe and effective when they are used as prescribed . However, if the patient experiences lack of efficacy from the prescribed treatment with topical corticosteroids-containing antipsoriatic drugs, this may be due to non-adherence. If the clinician is not attentive to this, the next step will be to subject the patient to treatments that carry a risk of skin cancer or burns , treatments with potentially severe side-effects such as severe immunosuppression, pancytopenia, and liver damage , and finally cost-intensive treatments without knowledge of long-term side-effects .
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