Limited, or mild-to-moderate, skin disease can often be managed with topical agents, while patients with moderate-to-severe disease may need phototherapy or systemic therapy. With proper adherence, considerable improvement with topical therapies may be seen in as little as one week, though several weeks may be required to demonstrate full benefits. Topical calcitriol ointment has been prescribed in Europe for years, and is now available in the United States. Patient information: Psoriasis (Beyond the Basics). The skin is made up of several layers (figure 1). About 40 percent of people with psoriasis or psoriatic arthritis (a type of arthritis closely related to psoriasis) have family members with the disorder (see Patient information: Psoriatic arthritis (Beyond the Basics) ). The pits look as if someone has taken a pin and pricked the nail several times (picture 5). While taking methotrexate, many providers recommend taking folic acid 1 mg daily or folinic acid 5 mg weekly to reduce the risk of certain methotrexate side effects, such as upset stomach and a sore mouth. Indeed, psoriasis patients on both etanercept and methotrexate exhibit augmented clinical responses. One acceptable treatment strategy for psoriasis is to initiate therapy with oral or injectable methotrexate at a standard dose of 10 to 25mg per week; after 8 to 12 weeks, PASI 75 is achieved by approximately 35 percent of patients. IGA scores of clear or almost clear were reported in 60 to 75 percent of patients. In a retrospective study of 49 patients with Bowen s disease (SCC in situ), topical imiquimod cream 5 was clinically effective, and 86 percent of patients had a complete response, while 14 percent failed therapy and required additional treatments.
The reported rate of ALT elevations during therapy has varied considerably, perhaps because of differences in frequency of determinations (every month vs every 3, 6 or 12 months) and due to the timing of the blood sampling (whether just before or soon after the once weekly dose). Patients who develop fibrosis on long term methotrexate therapy often have other risk factors for fatty liver disease, including excessive alcohol use, obesity, diabetes and concurrent administration of other potentially hepatotoxic agents. With more modern dose regimens (5 to 15 mg in one dose weekly with folate supplementation), fibrosis and clinically apparent liver disease are rare even with long term use. Patients with psoriasis involving more than 20 percent of their skin or those not responding to topical therapy are candidates for light therapy; traditional systemic therapy; or systemic treatment with immunomodulatory drugs such as alefacept, efalizumab, and etanercept. Estimates of the prevalence of psoriatic arthritis vary widely, but the authors of one study12 at a referral center found that one third of patients with psoriasis had arthritis and that, in two thirds of those with arthritis, skin lesions preceded arthritis. Complete clearing of lesions usually is not possible in patients who use only topical therapy, and overuse of topical therapies results in more side effects. 2001;70:11836. Psoriasis has both genetic and environmental aetiologies. 118, 141155 (1988).
Treatment of adults with moderate to severe chronic plaque psoriasis according to the criteria set forth in CPB 0658 – Psoriasis and Psoriatic Arthritis: Biological Therapies; or. Adalimumab can be used alone or in combination with methotrexate or other non-biolgic disease modifying anti-rheumatic drugs (DMARDs). Two studies involved 815 patients who had failed to respond to DMARDS; 1 study involved 619 patients who had an inadequate response to methotrexate. When methotrexate is used in a similar low-dose treatment for ectopic pregnancy, follow-up studies have demonstrated that menses returns normally and pregnancy rates are similar to those achieved by traditional surgical treatment of ectopic pregnancy. Participants were also instructed to return before misoprostol administration if bleeding had occurred after taking mifepristone that was equivalent to or heavier than menses. When cellulitis of any significance or symptoms of bacteremia are present, hospital admission for treatment with intravenous antibiotics is appropriate. One patient with advanced HIV disease and with chronic leg ulcers due to excoriation and folliculitis developed Pseudomonas overgrowth. The last patient we have seen with P. aeruginosa infection had cellulitis develop from hot tub folliculitis. Complete cure is difficult to achieve, and treatment is usually restricted to bothersome or distressing lesions.
Acitretin, a synthetic retinoid has gradually replaced etretinate in today’s dermatologic practice because of its more favorable pharmacokinetics. In a study by Gronhoj et al., on 86 patients on acitretin, a trend linking higher risk of etretinate formation with higher dose of alcohol consumption was found (all 16 patients with average 200 g/week alcohol intake having detectable etretinate). However, when used in combination with other topical and systemic therapies (topical corticosteroids, topical vitamin D preparations, psoralen with UVA (PUVA, ultraviolet B (UVB) therapy) it is as potent as classical therapies. Cancer 2012;118:2128-37. 30 active AS patients who were treated with an oral dose of 10 mg methotrexate weekly, has been published in abstract form 33. (40) or steroids (25) were allowed to continue taking them during the study. While many of these have shown safety and good efficacy in clinical trials of moderate-to-severe plaque psoriasis, long-term safety is still to be established. In this model, IL-17 is secreted by Th17 cells and is seen as one of the most important cytokines in psoriasis, while IL-23 drives Th17 cell activation 9. Clinical trial study endpoints often assess the percentage of patients who achieve a 75 reduction in PASI score, termed PASI 75, or a 90 decrease in PASI, termed PASI 90. 2010;362(2):11828.