Psoralen Plus Ultraviolet A
For this treatment, you’ll first be given a tablet containing compounds called psoralens, or psoralen may be applied directly to the skin. This makes your skin more sensitive to light.
Your skin is then exposed to a wavelength of light called ultraviolet A . This light penetrates your skin more deeply than UVB light.
This treatment may be used if you have severe psoriasis that has not responded to other treatment.
Side effects include nausea, headaches, burning and itchiness. You may need to wear special glasses for 24 hours after taking the tablet to prevent the development of cataracts.
Long-term use of this treatment is not encouraged, as it can increase your risk of developing skin cancer.
What Are The Implications
The review suggests topical steroids alone or in combination with vitamin D are more effective and safer at treating scalp psoriasis than vitamin D alone.
We should be cautious of taking these findings at face value as some trials were industry sponsored. An additional 14 trials were identified but unavailable for inclusion in the analysis. There is the potential that industry sponsorship favours publishing of positive results rather than negative findings. For this review most comparisons contained fewer than ten studies and the authors say they were not able to statistically test for this bias.
Other types of topical treatments, such as coal tar, were included in the scope of the review but there was insufficient evidence found to draw any conclusions.
When Should Topical Steroids Be Used
Topical steroids are one of the first treatment options for most people with psoriasis. They are most appropriate for people whose psoriasis covers only a small amount of their body, and should not be used on more widespread psoriasis.
Topical steroids may be used separately, or in combination with topical vitamin D treatments. It is recommended that a review appointment is arranged four weeks after starting any new topical treatment , so that your doctor can assess what the results of the treatment are so far, and to check if you need any help with using the treatment.
Topical steroids can also be used to treat psoriasis in sensitive areas such as the face, genitals and skin folds. Less potent steroids are usually used in the sensitive areas, and for a shorter length of time .
Some mild steroids are available to buy without a prescription, however it is always a good idea to speak to a doctor or pharmacist before using them.
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Precautions When Using Steroids
Most steroids are recommended for short-term use, but some people may need to be on them for longer periods of time. When youâre using steroids to treat psoriasis, your doctor should monitor your body weight, blood pressure, blood sugar, vision, and bone density.
If youâre taking systemic steroids, your doctor will likely recommend that you avoid individuals who are sick or have active infections. Systemic steroid use may put you at risk for severe infection from chicken pox, shingles, or the measles if youâre not already immune. You should also consult your doctor before receiving any vaccines while on systemic steroids. Because steroids suppress the immune system, a vaccine may not be as effective. The use of live-virus vaccines is also a concern for people taking steroids.
If youâre stopping long-term use of systemic steroids, work with your doctor to do it gradually over time. A sudden discontinuation of systemic steroids may lead to a serious condition called an adrenal crisis, which occurs because the body canât make enough cortisol to make up for the sudden withdrawal from the steroid. Side effects of an adrenal crisis include nausea, vomiting, and shock.
Formulations Of Topical Steroid
Several formulations are available for topical steroids, intended to suit the type of skin lesion and its location. Creams and lotions are general purpose and are the most popular formulations.
- The most suitable formulation for dry, non-hairy skin
- No requirement for preservative, reducing risk of irritancy and contact allergy
- Occlusive, increasing risk of folliculitis and miliaria
Gel or solution
- Has an astringent effect
- Stings inflamed skin
As a general rule, use the weakest possible steroid that will do the job. It is often appropriate to use a potent preparation for a short time to ensure the skin condition clears completely.
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How To Apply Safely
Topical corticosteroid should be applied in a thin layer and massaged into the affected area one to four times per day as directed. The treatment typically lasts until the psoriatic plaques resolve. In some cases, a stronger topical drug will be used to penetrate thickened plaques and switched to a milder form once the major scaling has been reduced.
Some corticosteroids are used on an intermittent basis whenever signs of a flare develop. These will usually be milder Class VI or VII drugs that can be applied when needed. Always check the expiration date and let your healthcare provider know well in advance if you need a refill.
Never apply a topical corticosteroid to skin other than that directed by your dermatologist. This is especially true with respect to the genitals and face.
Unless your healthcare provider tells you otherwise, never apply topical corticosteroids to the eyelids or under the eyes. Topical steroids should never be used internally or applied to cracked, bleeding, or infected skin.
Are Topical Steroids Safe
Serious side effects are uncommon or rare when topical corticosteroids are used exactly as directed and for the time intended, but may include:
- Cushing syndrome: Rare, but the risk is higher if large quantities of a topical corticosteroid are used long-term
- Glaucoma or cataracts caused by excessive use of topical steroids near the eye.
Topical steroids should not be confused with anabolic steroids often abused by body-builders to increase muscle mass.
For a complete list of severe side effects, please refer to the individual drug monographs.
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Side Effects And Other Warnings
With most topical retinoids, including tazarotene, skin irritation is always a possibility. This irritation can include moderate to mild:
Less common side effects include blisters and skin discoloration.
You may also have more sensitivity to the sun when you use tazarotene. Itâs more important than ever that you remember to wear broad-spectrum sunscreen and protective clothing if you spend time in the sun after youâve applied your medication.
You shouldnât try a topical retinoid for your psoriasis if youâre pregnant. It might not be safe when youâre breastfeeding either, but the research on that is less clear. If you’re breastfeeding, make sure your doctor knows before you try this topical treatment, and talk about any possible risks.
People who have skin cancer also may not be able to use this medication safely.
If you have eczema in addition to psoriasis topical retinoids could cause a flare-up. Itâs rare â it happens to fewer than 1 in 10 people with eczema â but itâs worth discussing with your doctor.
Differentiating Scalp Psoriasis From Seborrheic Dermatitis
Localized scalp psoriasis sparing other body areas may be easily confused with seborrheic dermatitis. Differentiation on dermoscopy can be done by looking for the vascular patterns and types of scales. Psoriasis is characterized by an extensive array of red dots, globules, and glomerular vessels . The red dots appear as twisted capillary loops on higher magnification. These vascular findings correspond to the dilated capillaries seen in the dermal papillae on histopathology. The number of twisted loops correlates with disease severity .
Seborrheic dermatitis is characterized by thin arborizing capillaries and atypical red vessels . In scales are dry, silvery white in psoriasis and greasy, yellowish in seborrheic dermatitis . A study by Kim et al. found no significant difference in the frequency and characteristics of the scales in both of the conditions on dermoscopy. It was concluded that vascular patterns are more valuable for differentiation . An algorithmic approach to trichoscopy aided diagnosis of alopecia .
Table 4.1. Algorithmic Approach for Diagnosis of Cicatricial and Noncicatricial Alopecia
DLE, Discoid lupus erythematosus LPP, lichen planopilaris CTE, chronic telogen effluvium AA, alopecia areata AI, alopecia incognito AGA, androgenetic alopecia UV, ultraviolet.
From Kharkar V. Overview of trichoscopy. In: Khopkar U, editor. Dermoscopy and trichoscopy in diseases of the brown skin. 1st ed. New Delhi: Jaypee 2012. p. 16981.
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Calcineurin Inhibitors: Pimecrolimus And Tacrolimus
If psoriasis affects sensitive areas of skin for instance on your face, in your groin area or your armpits calcineurin inhibitors are sometimes used as an alternative to corticosteroids. This group of medications includes creams and ointments containing pimecrolimus and tacrolimus. Tacrolimus is the stronger of the two drugs.
Unlike steroids, calcineurin inhibitors dont make your skin thinner. But they were originally developed for the treatment of and havent been approved for the treatment of psoriasis. So certain things have to be taken into consideration if they are used for the treatment of psoriasis. For instance, its important to contact your health insurer before starting the treatment in order to find out whether they will cover the costs.
Also, theres a lack of good-quality research on the effectiveness of calcineurin inhibitors in the treatment of psoriasis, so its difficult to say whether they work as well as corticosteroids do.
Why Topicals May No Longer Be Enough
You may also notice that a topical treatment simply doesnt control your symptoms like it once did. That may be because your psoriasis has become more severe or youve developed a tolerance to topical therapies, including steroids, which lessens their effectiveness.
While there are many theories about why that happens, I do think its a real phenomenon, Lebwohl says. They just stop working.
Its also possible that if you stop using a topical treatment as often as your doctor prescribed, it could lose its effectiveness, according to a review published in July 2015 in the journal Psoriasis: Targets and Therapy.
Although older topicals tended to be greasy ointments that were often less effective, newer topicals come in easier-to-use foams and lotions that work well for many people without the mess. These products should make it easier to stick to your treatment plan, Lebwohl notes.
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Topical Versus Systemic Treatments
If your doctor determines that topicals arent sufficient to manage your psoriasis, they may move you to a systemic therapy, says Lebwohl.
Unlike topical medications, which are applied directly to the affected area of skin, systemic psoriasis treatments are taken orally or injected and work throughout the body to help control the inflammation that causes psoriasis. Theyre typically prescribed if you have moderate to severe psoriasis or your symptoms no longer respond to topical treatments.
Examples of systemic treatments for psoriasis include:
Conventional disease-modifying antirheumatic drugs : This class of drugs controls psoriasis by suppressing inflammation, according to the NPF. Conventional DMARDs, such as methotrexate and cyclosporine, reduce inflammation by suppressing the immune system on a broad level. Thats why they tend to cause more side effects than newer drugs and carry warnings about increased risk of infection, Lebwohl says.
Biologics: Biologics are a type of DMARD made from living cells, according to the NPF. Unlike conventional DMARDs, which affect the immune system broadly, biologics target and block a single molecule in the immune system thats responsible for psoriasis symptoms, explains Lebwohl. That often means fewer side effects.
Newer biologic drugs are particularly effective and safe, he notes. But keep in mind that some biologics may take a few months to work.
What You Need To Know About Psoriasis Potency Topical Steroid Scalp Psoriasis
Is Your Stomach to Blame?
Who would have thought that a severe psoriasis outbreak could start because of something going wrong inside of your stomach and intestines? Yet, new research developed by psoriasis expert Edgard Cayce shows a distinct link between a leaky gut and a scaly psoriatic episode. According to Cayce, the primary source of psoriasis can be found in the intestinal tract, where toxins are leached into the body. This causes the immune system to react by thickening the skin. At the same time, the skin tries to purge the toxins through its layers, which can cause scabs and sores to form.
Could Arthritis Be the Cuplrit?
The intestines arent the only link to psoriasis found by researchers arthritis seems to also contribute to it. As many as one-third of all psoriasis patients eventually develop some form of psoriatic arthritis. Unlike normal forms of arthritis, those with psoriatic arthritis do not exhibit a rheumatoid factor when their blood is tested. This indicates that the arthritic condition comes solely from either the psoriasis itself or the underlying cause of the skin affliction.
Could a Virus Be the Cause?
Arthritis has been linked to certain virus and so have other auto-immune disorders. This leads some researchers to think that psoriasis too may start with a virus, which is what kicks the immune system into overdrive.
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Topical Steroids Better Than Vitamin D For Treating Scalp Psoriasis
This is a plain English summary of an original research article
Topical steroids applied to the scalp were more effective and safer for treating psoriasis than topical vitamin D alone.
Using steroids in combination with vitamin D was statistically better than using a steroid alone, but the difference was not considered clinically important. The combination ointment costs almost £20 for 30g compared to a 30g tube of typical steroid ointment which costs about £4.
Scalp psoriasis is a common condition that can be itchy and embarrassing for many. A variety of topical lotions, solutions or gels are available to treat the condition, so this review of published research aimed to help doctors and patients find out which was the most effective and safest option.
This systematic review found 59 trials mainly of steroids or vitamin D, alone or in combination, lasting less than six months. Just over half were known to be sponsored by the manufacturers of the products. This could mean that the results may be biased towards the publication of positive results. Another limitation is that the results are relevant to short term, less than 6 month use only.
The results are in line with current NICE guidelines, which recommend topical steroids alone first-line in different formulations and, if that doesnt work, a combination of steroid and vitamin D.
Topical Steroid In Pregnancy
Mild and moderate-potency topical steroids can be safely used in pregnancy. Caution should be used for potent and ultrapotent topical steroids used over large areas or under occlusion, of which a proportion will be absorbed systemically.
Reports of low birth-weight infants exposed to high-dose topical steroid are not thought to be due to the medication.
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Topical Steroid Potency Chart
Curious about the potency of topical steroids? Perhaps your health care provider prescribed you a treatment and youâd like to know how potent it is.
Below you will find a chart of topical steroids classified by their potency. Both the brand names and generic names are listed.
Are you looking for non-steroid or over-the-counter options? While topical steroids require a prescription from a health care provider, there are over-the-counter and non-steroid treatment options available to you without a prescription.
NPF’s Seal of Recognition has a searchable list of products like shampoos and moisturizers, and even household items, all of which are made or intended to be non-irritating to your sensitive skin.
How To Use A Topical Steroid
Topical steroid is applied once daily to inflamed skin for a course of 5 days to several weeks. After that, it is usually stopped, or the strength or frequency of application is reduced.
Emollients can be applied before or after the application of topical steroid, to relieve irritation and dryness or as a barrier preparation. Infection may need additional treatment.
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Topical Steroids For The Scalp
I still use a topical solution and an oil on my scalp, which effectively address the scaling and itch but make my hair completely unpresentable. The topical solution, which I apply in streaks on my scalp and then rub in to spread, gives me a greasy look that resigns me to a messy bun my only hairstyle since psoriasis. I apply the oil a couple times a week and then sleep with a shower cap on, but this only works if I plan to wash my hair the next morning. Washing my scalp irritates my scalp psoriasis: The itch is always the worst after a shower, so I always struggle to decide whether oiling is worth it. I am also still using a liquid steroid in the form of eardrops to address the psoriasis in my ears another one of my itchier spots.
Topical Pharmaceutical Formulations Made With Olive Oil
The physician Galen designed the first moisturizing cream made of olive oil, using also water and vegetal wax. This cream demonstrated great moisturizing properties and increased the elasticity of skins. Olive oil has also been classically added to bath water. The formulation of olive oil with vaseline and menthol allows to obtain cosmetic products with good moisturizing properties. Olive oil is also used as massage lubricant due to its capability to induce the relaxation of muscles and nerves. It is also recommended by dermatologists in the treatment of hemorrhoids in pregnant women, ulcers, mycotic infections of the scalp and in the pre-treatment of scalp psoriasis . This vegetable oil is also taken orally, inducing smoothness and brightness to the skin, hair and cuticles of the nails.
One of the main applications of olive oil is the preparation of skin formulations with a protective and moisturizing action on the epidermis. There are several cosmetic products prepared with olive oil, such as baby foams or nutritive bath gels .
Table 124.3. Composition of pharmaceutical formulations containing olive oil or oleic acid.
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