Treatment Of Psoriasis: An Algorithm
ASHA G. PARDASANI, M.D., STEVEN R. FELDMAN, M.D., PH.D., and ADELE R. CLARK, P.A.-C., Wake Forest University School of Medicine, Winston-Salem, North Carolina
Am Fam Physician. 2000 Feb 1 61:725-733.
See related patient information handout on psoriasis, written by the authors of this article.
Psoriasis is characterized by red, thickened plaques with a silvery scale. The lesions vary in size and degree of inflammation. Psoriasis is categorized as localized or generalized, based on the severity of the disease and its overall impact on the patient’s quality of life and well-being. Patient education about the disease and the treatment options is important. Medical treatment for localized psoriasis begins with a combination of topical corticosteroids and coal tar or calcipotriene. For lesions that are difficult to control with initial therapy, anthralin or tazarotene may be tried. The primary goal of therapy is to maintain control of the lesions. Cure is seldom achieved. If control becomes difficult or if psoriasis is generalized, the patient may benefit from phototherapy, systemic therapy and referral to a physician who specializes in the treatment of psoriasis.
How Should This Medicine Be Used
Ustekinumab comes as a solution to inject subcutaneously or intravenously . For the treatment of plaque psoriasis and psoriatic arthritis, it is usually injected subcutaneously every 4 weeks for the first two doses and then every 12 weeks for as long as treatment continues. For the treatment of Crohn’s disease and ulcerative colitis, it is usually injected intravenously for the first dose and then given subcutaneously every 8 weeks for as long as treatment continues.
You will receive your first subcutaneous dose of ustekinumab injection in your doctor’s office. After that, your doctor may continue to give you injections or allow you to inject ustekinumab injection yourself or have a caregiver perform the injections. Ask your doctor or pharmacist to show you or the person who will be performing the injections how to inject ustekinumab. Before you use ustekinumab injection yourself the first time, read the written instructions that come with it.
If your medication comes in a prefilled syringe or vial, use each syringe or vial only once and inject all the solution in the syringe. Even if there is still some solution left in the syringe or device, do not use it again. Dispose of used needles, syringes, and devices in a puncture-resistant container. Talk to your doctor or pharmacist about how to dispose of the puncture-resistant container.
Do not shake a prefilled syringe or vial that contains ustekinumab.
Ustekinumab Injection May Cause Side Effects Tell Your Doctor If Any Of These Symptoms Are Severe Or Do Not Go Away:
- runny, stuffed nose, or sneezing
- redness or irritation at the injection site
- swelling of the face, eyelids, tongue, or throat
- difficulty breathing
- tightness in the chest or throat
Ustekinumab injection may increase the risk that you will develop cancer. Talk to your doctor about the risks of using this medication.
Ustekinumab injection may cause other side effects. Call your doctor if you have any unusual problems while using this medication.
If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration’s MedWatch Adverse Event Reporting program online or by phone .
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How Biologics Will Affect Your Psoriasis
Whether you start with a biologic drug or turn to one after trying other therapies, you should see dramatic results. But you need to follow your doctor’s instructions for any treatment carefully. And youâll need to go in for regular follow-up visits to make sure your treatment is still working. At your visits, talk about any problems or side effects you are having.
Biologic Therapy For Psoriasis
In a relatively short period of time, biologic drugs have revolutionized the way doctors treat psoriasis and other autoimmune diseases.
There are now many biologics approved to treat psoriasis in the United States, with others in the pipeline.
The first-line treatment for psoriasis is often topical steroid creams, but if those don’t work, your doctor may prescribe a biologic medication right off the bat, says Bruce Strober, MD, PhD, clinical professor of dermatology at Yale University and founder of Central Connecticut Dermatology Research in Cromwell, Connecticut.
Doctors also turn to these drugs first when a large area of the body is affected by psoriasis or the psoriasis is taking a dramatic toll on quality of life.
“The impact of biologic therapy is indescribably enormous,” he says. “Medical dermatology is vastly different now than it was 20 years ago when I was in training.”
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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.
What Are Biologic Drugs
Given as IV infusions or injections at home or in a doctor’s office, biologic drugs are genetically engineered proteins that target specific parts of the immune system that drive inflammation.
There are several classes of biologic drugs they are organized largely by which inflammatory protein or proteins they target.
Categories of biologics include tumor necrosis factor inhibitors , interleukin inhibitors, B-cell inhibitors, and selective costimulation modulators . TNF blockers and interleukin inhibitors are the classes of biologics currently used to treat psoriasis, though there’s an immunomodulator that can treat psoriatic arthritis.
Biologics can be used with other psoriasis treatments, including UV light therapy, topical steroids, or systemic medications such as methotrexate. Or they might be used on their own.
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Saving Money On Psoriasis Treatment
Check out the Financial Assistance Resource Center at the National Psoriasis Foundation website. The page lists where to find financial aid programs and health insurance support services.
Dont skip psoriasis treatment because it will cost you lots of money. If cost is an issue for you, talk with your doctor about how you can get the treatment you need for less.
Risks Of Biologic Psoriatic Arthritis Treatment
Because biologic medication weakens your immune system, it can also increase your risk of getting an infection or reactivating a prior infection such as hepatitis B or tuberculosis.
There is always a possibility of having an allergic reaction when taking medication. If you experience shortness of breath, fever, chills, numbness, tingling, rash, or redness, itchiness, or pain at the injection site, contact your doctor immediately since these are possible signs of an allergic reaction.
The most common adverse effects from biologic injections include pain, swelling, itching, rash, and redness at the injection site. If you have any of these symptoms, talk to your doctor about switching your medication.
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Salicylic Acid And Coal Tar
Coal tar and salicylic acid can be less costly options than some prescription treatments, Tomaka said. Be careful not to leave the salicylic acid on for too long, as it can irritate the skin. Tar derived from coal is best for psoriasis. Coal tar can help reduce inflammation, scaling, and itching of psoriasis. The more coal tar a product contains, the more potent it will be.
Coal tar makes your skin more sensitive to sunlight, Tomaka warned. Also, it remains active on your skin for a minimum of 24 hours.
Why Is This Medication Prescribed
Ustekinumab injection is used to treat moderate to severe plaque psoriasis in adults and children 6 years or older who may benefit from medications or phototherapy . It is also used alone or in combination with methotrexate to treat psoriatic arthritis in adults. Ustekinumab injection is also used to treat Crohn’s disease in adults. Ustekinumab injection is also used to treat ulcerative colitis in adults. Ustekinumab injection is in a class of medications called monoclonal antibodies. It works by stopping the action of certain cells in the body that cause the symptoms of plaque psoriasis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis.
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More Fit Less Psoriasis
While some researchers focus their attention on coming up with new psoriasis treatments, others look at ways to avoid this skin disorder. One promising avenue of prevention centers on fitness.
Studies find that exercise, especially when itâs intense, might help reduce the chance of getting psoriasis. People who are less fit seem to have a higher risk for the disease. Although the link needs to be explored further, it may be about how exercise can lower chronic inflammation, a hallmark of psoriasis and many other conditions.
What Should I Know About Storage And Disposal Of This Medication
Keep this medication in the container it came in, tightly closed, and out of reach of children. Store ustekinumab vials and prefilled syringes in the refrigerator, but do not freeze them. Keep the vials and prefilled syringes upright in their original cartons to protect them from light. Dispose of any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication.
It is important to keep all medication out of sight and reach of children as many containers are not child-resistant and young children can open them easily. To protect young children from poisoning, always lock safety caps and immediately place the medication in a safe location â one that is up and away and out of their sight and reach.
Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. However, you should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program. Talk to your pharmacist or contact your local garbage/recycling department to learn about take-back programs in your community. See the FDA’s Safe Disposal of Medicines website for more information if you do not have access to a take-back program.
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What Nail Psoriasis Looks Like
Nail psoriasis causes changes to your fingernails and toenails
This fingernail shows 3 signs of nail psoriasis: Crumbling, roughness, and blood under the nail .
Common signs of nail psoriasis
This nail also has 3 signs of nail psoriasis: Tiny dents in the nail , white discoloration, and lifting .
Most people who have plaque psoriasis develop nail psoriasis
Discoloration , nail lifting from the finger, and a thin line of blood are common signs of nail psoriasis.
Nail psoriasis usually begins years after psoriasis first appears on the skin
This patients nail has 3 common signs of nail psoriasis: Grooves, blood beneath the nail , and lifting of the nail from the finger.
Nail psoriasis can be mild
If you have psoriasis, ridges and a thin line of blood beneath the nail can be signs of nail psoriasis.
Improvement from treatment happens slowly
Nails grow slowly, so it will take 6 months or longer to clear debris, a common sign of nail psoriasis, beneath the nail.
Understand The Differences In Injectable Medications
Is the injection a good move or a bad one? asked one MyPsoriasisTeam member.
There isnt a simple answer to that question. There are various injectable medications used for different types of psoriatic disease. Your doctor may have to run some medical tests before determining which injectable medication is appropriate for you. Injectable medications for psoriasis may include corticosteroids, immunomodulators, or biologics.
A corticosteroid like Kenalog can be delivered into the joint of a person to treat psoriatic arthritis. It can also be locally injected subcutaneously under the skin. Immunomodulators like methotrexate can be injected subcutaneously. Biologics may be prescribed in conjunction with methotrexate or as stand-alone treatment. Humira is one of the most popular biologics, and it is also injected subcutaneously. Other biologics, such as Remicade , are delivered through an IV.
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How Well Do The Biologic Drugs Work To Relieve Arthritis Caused By Psoriasis
All six biologic drugs included in our analysisadalimumab , certolizumab , etanercept , golimumab , infliximab , and ustekinumab are FDA-approved to treat psoriatic arthritis. The biologic drugs reduce joint pain and inflammation and improve the quality of life in up to 80 percent of people with this condition.
There are no head-to-head trials of biologic drugs to treat arthritis caused by psoriasis. Other studies that attempted to compare them indirectly had mixed results, but most found no difference in effectiveness among Humira, Enbrel, and Remicade. Simponi was approved after these studies were done. In the only major study of Simponi, about half of people who received it had at least a 50 percent improvement in joint pain, swelling, and function.
Ultraviolet Treatment For Psoriasis
is the use of UV radiation to treat skin disorders, and this can be very effective in the treatment of psoriasis. It is generally reserved for cases where topical therapy has been ineffective or too much of the skin surface is involved to treat psoriasis effectively with topical agents. It is administered in cabinets at specialised centres, and a treatment course for psoriasis will usually consist of 23 treatments per week for 2030 treatments.
- Phototherapy is best avoided in patients with very fair skin, who take certain immunosuppressive medications, or who have a previous history of skin cancer.
The need for regular travel to a phototherapy centre can make this option difficult for some patients. The beneficial effects may be short-lived.
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Complementary And Alternative Treatments
Youll find plenty of these for treating psoriasis. The US Food and Drug Administration doesnt regulate these products. As such, few of these treatments have been studied. Those that have been studied were tested on small numbers of people, so we dont know how well these treatments work. We also dont know whether theyre safe.
For Best Results From Treatment
Treating nail psoriasis can be a challenge. It often takes time to treat. To get results, you need to treat your nails as directed and for as long as directed. Some patients need to try a few treatments to find one that works.
The right nail care can help you get the best results from treatment. Youll find out what dermatologists recommend at: 7 easy-to-follow nail care tips that can reduce nail psoriasis
ImagesImages used with permission of the Journal of the American Academy of Dermatology. J Am Acad Dermatol 2013 69:249.
ReferencesCrowley JJ, Weinberg JM, et al. Treatment of nail psoriasis: Best practice recommendations from the Medical Board of the National Psoriasis Foundation. JAMA Dermatol. 2015 Jan 151:87-94.Dogra A, Arora AK. Nail psoriasis: The journey so far. Indian J Dermatol. 2014 Jul 59:319-33.Lin YK, Chang YC, et al. A Chinese herb, indigo naturalis, extracted in oil used topically to treat psoriatic nails: A randomized clinical trial. JAMA Dermatol. 2015 Jun 151:672-4.Manhart R, Rich P. Nail psoriasis. Clin Exp Rheumatol. 2015 Sep-Oct 33:7-13.van der Velden HMJ, Klaassen KMG, et al. Fingernail psoriasis reconsidered: A case-control study. J Am Acad Dermatol 2013 Aug 69:245-52.
All content solely developed by the American Academy of Dermatology
The American Academy of Dermatology gratefully acknowledges the support from Amgen and .
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Treating Psoriasis On A Budget
The cost of managing a chronic condition like psoriasis can soar. But by using generic drugs, coupons, and even household products, you may find physical and financial relief.
Psoriasis is a chronic condition, and treating it can get expensive. A survey by the National Psoriasis Foundation found that more than 90 percent of psoriasis and psoriatic arthritis patients have health insurance public or private and yet nearly half said they go without treatment at some point for financial reasons. So, are there ways of saving money while finding relief by treating psoriasis on a budget?
Many people with severe psoriasis have found relief from a relatively new class of drugs known as biologics. Given by injection or intravenous infusions, biologics can cost $18,000 to $28,000 a year per patient, and no generic alternatives are available.
Even those who are treated with creams, ointments, and lotions find that those can get pricey. A single tube of some prescription psoriasis medications can cost $500 to $600.
Fortunately, there are ways to save money on psoriasis treatment without sacrificing success.
What Drugs Interact With Humira
Humira may interact with azathioprine or mercaptopurine. Asacol may also interact with pentamidine, tacrolimus, amphotericin B, antibiotics, antiviral medicines, cancer medicine, or aspirin or other NSAIDs .
Humira may also interact with abatacept, anakinra, infliximab, etanercept, certolizumab pegol, golimumab, or rituximab.
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