Kosmet Med 2012 (6): 226 – 237

PSORIASIS VULGARIS UPDATE 2012 (PART 2): THERAPY
Psoriasis vulgaris Update 2012 (Teil 2): Therapie

WOLFGANG RAAB

KEY WORDS: Corticosteroids, retinoids, vitamins D-analoga, methotrexate, cyclosporine, phototherapy, PUVA, biologics. Plaque psoriasis, nail psoriasis, psoriasis arthropathica

SUMMARY:
In all forms of psoriasis, the basic treatment consists in skin care, psychosocial measures, and climate therapy. Depending on the extent and acuity of the disease, topical and/or systemic measures are chosen. The target of every antipsoriatic treatment of plaque psoriasis as well as of psoriatic arthritis is a reduction of the PASI to 25 % of the initial value within three to four month. If this result is not achieved, the therapy must be adapted (increase of dose, shortening of intervals, change of the drug in use, additional prescription of another antipsoriatic drug). In psoriatic nail disease, if therapeutic success of local measures does not occur within a few weeks, systemic therapy preferably with biologics should be started in order to prevent irreversible nail changes.

In light cases with a PASI below 10, topical treatments mostly are sufficient. Vitamins D analoga on limited areas with or without corticosteroids are the treatment of choice after removal of the scales with salicylic acid or urea. Attention has to be paid to the action of vitamins D-analoga on calcium and phosphate metabolism. Colouring substance or substances with an unpleasant smell are no longer in use.

In more severe cases with a PASI above 10, phototherapy or photochemotherapy (PUVA) are used for the treatment of the psoriatic plaques. However, the possible elicitation of skin cancer limits the use of these therapies. The patient must be informed about the possibility of such events. Wide-spread skin changes as well as psoriatic arthritis and affections of the nails need a systemic treatment with cyclosporine, methotrexate or retinoids. The introduction of biologics has led to a profound change in antipsoriatic treatment. In generalized plaque psoriasis, in psoriatic arthritis, and in nail psoriasis these new substances have ameliorated the therapy to a significant extend. Biologics do not only exert antipsoriatic effects on skin, joints, and nails, but they improve comorbidities as well. The possibility of undesirable actions requires regular controls of the patient.

Biologicals: With the development of biologicals the treatment of psoriasis as a whole experienced a re-evaluation. Is there a need of a systemic therapy, one should think of using biologicals, when all other systemic treatments fail. One should not forget, that biologicals slow down the development of comorbidities. With Psoriasis ungium one should not hesitate to luse biologicals, since damage to the nails occurs quite rapidly. Which biological in which cycles over how many weeks should be administered, depends individually on the possibilities and the experience of the doctor and the condition e.g. the treatment response of the patient. Biologicals almost always give the psoriatic patient fast relieve with an easy and strainless therapy. Regular controls are indispensable. An additional local treatment improves the results even more.