History of psoriasis treatments. UV phototherapy for psoriasis, vitiligo, dermatitis, hyperhidrosis,
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The history of psoriasis treatments

Psoriasis is a chronic disease requiring continuous treatment.

There is no cure for psoriasis.

Different treatments can help reduce or temporarily eliminate the symptoms of psoriasis, but no one treatment works for everyone.

In recent years, new biological therapies have been introduced and several existing treatments improved giving new hope to people with psoriasis

Although psoriasis has been recorded since biblical times, improvements in the treatment of this disabling, disfiguring and painful skin disease really only occurred in the second half of the 20th century. As yet, there is no cure for psoriasis, but patients now have a range of topical, systemic and ultraviolet light-based treatments that can control and temporarily eliminate the symptoms of the disease. The 21st century has seen the introduction of a new class of psoriasis treatment - the biological - bringing new hope to people with psoriasis around the world.

prior to last century, people with psoriasis had little choice of treatment to control their psoriasis. Because the skin disease was poorly understood and thought to be contagious, psoriasis sufferers were shunned and even confined to leper colonies.

Today, treatment of psoriasis can be divided into three basic categories:

Topical treatment (treatments applied to the skin)

phototherapy or a combination of phototherapy and medications

Systemic treatment (medications taken by tablet or injection)

A number of factors will determine which treatment will best suit a person with psoriasis. These include:

The type of psoriasis

Its location on the body

Its severity

The person's age and medical history

The person's response to previous therapy

psoriasis Treatment Through the Ages

Over 100 years ago: - dithranol; coal tar; salicylic acid; sunlight; Dead Sea salts; emollients

1920s: - ultraviolet light (UVB); Goeckerman regimen

1950s: - topical and oral steroids

1960s: - Hydroxyurea

1970s: - PUVA (psoralen plus UVA)

1980s: - methotrexate

1990s: - topical vitamin D3; retinoids; Cyclosporin

2000s: - biological therapies; laser treatment

Topical therapy

Topical therapies are usually the first line of defence in treating psoriasis. They generally work relatively quickly at clearing the immediate lesions after application and are also usually well tolerated. However, topical treatments have to be used repeatedly to be effective, as they are not good at maintaining remission of the disease. They can also be messy and take a long time to apply if the psoriasis covers a large portion of the body.

Dithranol (also known as anthralin in certain parts of the world)

Dithranol is a topical therapy that has been used to treat psoriasis for over a century. It is derived from Goa powder from the bark of the arroba tree.

Dithranol can be effective for mild to moderate psoriasis and is often used with ultraviolet B (UVB) treatments (see below) for more severe psoriasis.

A short application with high concentrations of dithranol has been shown to be as effective as an overnight or daylong application using lower concentrations.

There are, however, some key weaknesses that limit its use in psoriasis: it causes irritation and burning to the skin and it tends to stain anything it comes into contact with.

 

Corticosteroids for psoriasis

Topical corticosteroids - the most commonly prescribed treatments for psoriasis in many parts of the world - are synthetic drugs that resemble naturally-occurring hormones in the body. They are available in many strengths and formulations including creams, lotions, solutions, emollients, sprays, gels, ointments and medicated tapes.

Corticosteroids act by slowing down the growth of skin cells and decreasing the inflammation of lesions in patients with psoriasis. Although corticosteroids can quickly clear lesions, they typically do not produce long remissions, so the lesions associated with psoriasis often recur after a short time.

Side effects of prolonged corticosteroid use are numerous and include cutaneous atrophy, the formation of telangiectasia (elevated dark red blotches on the skin) and striae (stretch marks), the latter scars' are permanent.

 

Coal tars for psoriasis

Topical coal tars have helped treat psoriasis for centuries and can be used by themselves or combined with UVBi (see below). By making the skin more sensitive to UV light, coal tar can cause a greater sensitivity to burning when combined with UV therapy. In fact, coal tars were once used as an essential component of the Goeckerman regimenii (see below).

The use of tars slowed down when it was shown that other emollients (substances used to soothe the skin) were equally effective when used in conjunction with UVB light.i

The staining caused by tars has also greatly limited their use and attempts to make non-greasy tar preparations that do not stain the skin have not been successful.

Coal is also a designated carcinogen (COSHH - Committee of Substances Hazardous to Health, UK).

 

Retinoids - topical for psoriasis

Retinoids (vitamin A derivatives) are the most recent developments for the topical treatment of psoriasis. Tazorotene is a retinoid used to treat mild to moderate plaque psoriasis, which can be used on most parts of the body, including the face, hairline and scalp.

Local irritation caused by retinoids has limited their use.ii

 

Vitamin D analogues for psoriasis

The introduction of calcipotriol in the early 90s has provided an alternative to topical steroids, tars and dithranol. Calcitriol and tacalcitol have subsequently been introduced. Calcipotriol has shown equal or superior efficacy to other agents and is cosmetically more acceptable and generally well tolerated. However, local irritation does occur. These agents are not associated with the cutaneous atrophy of corticosteroids or the messiness of tars and dithranol.ii

 

Salicylic acid for psoriasis

Salicylic acid is a chemical that helps remove scale on lesions. This then allows topical medications to better penetrate the skin. It can be applied as a paste or in creams / ointments / lotions.

Non-prescription skin treatments

A variety of over-the-counter products including moisturisers, bath oil, Epsom salts and oiled oatmeal may be helpful in treating psoriasis in some people. They do not work for everyone, but they are unlikely to cause harmful side effects.

Applied regularly over a long period, moisturisers can soothe the skin and relieve itching and scaling. Thick, greasy preparations that hold water in the skin usually work best.

 

Phototherapy

patients with psoriasis that does not respond to or is too widespread for topical treatments are candidates for phototherapy. This involves exposing the skin to wavelengths of UV light, which has a therapeutic benefit in psoriasis. Phototherapy is a standard treatment for patients with moderate to severe psoriasis who have not responded to topical therapies.

 

Climatotherapy

Sunlight can have a beneficial effect on psoriasis. Climatotherapy has been used in the Dead Sea, Israel, for many years.ii Because of its position at the lowest point on earth and the haze of minerals in the atmosphere over the Dead Sea, burning rays of short wavelength UVB light are filtered out, allowing more exposure to longer wavelength therapeutic UVB rays.

 

Broadband and narrowband UVB

This form of phototherapy involves exposing the skin to a particular wavelength of UV light called UVB that is effective for treating psoriasis. UVB is present in natural sunlight.

Broadband UVB phototherapy has been used to treat psoriasis since the 1920s.

Studies have shown that the optimum wavelength of UVB for the treatment of psoriasis is close to 311 nm and this has lead to the development of bulbs that emit UVB radiation in a narrowband' at this optimum wavelength.

Narrowband UVB is significantly more effective than broadband UVBii and thus far seems to be substantially safer than PUVA (see below).

PUVA (psoralen plus UVA)

PUVA, also called photochemotherapy, was developed in the 1970s and involves the combination of a light-sensitising medication (psoralen) followed by irradiation with UVA (like UVB, UVA is found in natural sunlight).ii psoralen makes the skin more sensitive and responsive to this type of UV light.

Bath pVA is also practiced where the psoralen is put in a bath: the patient soaks before entering the UVA cabinet.

Long-term PUVA therapy can lead to premature ageing of the skin and also increases significantly a person's risk of skin cancer (basal cell carcinoma and superficial cell carcinoma).ii Consequently, the maximum recommended exposure should not be exceeded.

 

The Goeckerman regiment for psoriasis

Patients with severe or disabling psoriasis may go to hospital or psoriasis treatment centres for concentrated treatment with UVB and topical coal tar. This is known as the Goeckerman regimen and usually takes at least three or four weeks of daily treatment.

Laser therapy

Although used previously in the treatment of varicose veins and skin discoloration, lasers are a new treatment for psoriasis. The excimer laser emits a high-intensity beam of UV light targeting selected areas of skin.

The excimer laser is usually for mild to moderate levels of disease where lesions cover less that 10 per cent of the body.

pulsed dye lasers are also primarily used to treat small, localised areas of psoriasis. Instead of one continuous beam of light, they emit short bursts of high-intensity yellow light.

Side effects of laser treatment include a small risk of scarring and bruising.

Systemic treatments

In patients who do not respond to phototherapy or who cannot comply with the frequent phototherapy visits needed to achieve clearing, several systemic drugs are available. Systemic drugs affect the whole body.

 

Methotrexate

Methotrexate was initially developed as a treatment for cancer. It has also been used for many years in the treatment of psoriasis. It works by binding to an enzyme involved in the growth of cells and therefore slows down skin-cell growth in psoriasis. Because of its mechanism of action, methotrexate also affects normal cells, including foetal cells, bone marrow and sperm cells.

One of the big disadvantages of methotrexate is that its long-term use has been associated with liver damage and in many countries guidelines call for routine liver biopsies in patients taking long-term methotrexate.ii

In a recent study , it was shown that 48% of patients were not able to stay on treatment after one year.

 

Cyclosporin

Cyclosporin appears to slow down the rate of skin growth by inhibiting the immune system (the immune system plays a critical role in the development of psoriasis).

Cyclosporin has been used for the treatment of psoriasis for more than a decade. However, its long-term use is associated with nephrotoxicity (kidney damage)ii and the American Academy of Dermatology (AAD) guidelines stipulate a maximum use of one year.

 

Oral retinoids

Retinoids are derivatives of vitamin A. They affect how cells regulate their behaviour, including how quickly they grow and shed from the skin's surface. Oral retinoids are only moderately effective as monotherapy and are associated with numerous side effects such as hair loss and thinning of the nails.

When used in combination with UVB phototherapy or PUVA, low doses of the retinoid acitretin are very effective, allowing substantial clearing with fewer phototherapy visits and fewer side effects.ii

Retinoids have been associated with birth defects, so they cannot be given to women who could potentially become pregnant. Retinoids treatment has to have been stopped for three year before a woman can become pregnant.

 

Biological therapies

Innovations in biotechnology have the potential to offer high efficacy and greater safety in the treatment of psoriasis by building targeted natural protein-based drugs that interfere with specific steps in the pathogenesis of psoriasis.

The biologicals target the immune system by blocking the action of certain immune cells that play a role in psoriasis. Whereas other psoriasis treatments such as PUVA, methotrexate and cyclosporin also affect the body's immune system, the action of the biologicals is more specific and they have the potential to be a safer treatment option.

Several biologicals are in development. These include efalizumab, alefacept, etanercept and infliximab. Efalizumab and Etanercept are currently available in several countries.

Biologicals are taken by injection and are mostly prescribed for moderate to severe psoriasis.

 

References

i Van de Kerkhof pC. Therapeutic strategies: rotational therapy and combinations. Clin Exp Dermatol 2001; 26:356 -361.

ii Lebwohl M. Psoriasis. Lancet 2003;361:1197-1204.

iii Larko O. Treatment of psoriasis with a new UVB-lamp. Acta Dermatol Venereol 1989;69:357-359

iv Heyendael V.M.R, et al. Methotrexate versus Cyclosporine in Moderate-to-Severe Chronic plaque psoriasis. New England Journal of Medicine 2003;349:658-65

Availability of psoriasis treatments is increasing as governments slowly spend more money on researching treatment for this skin disease. Established treatments include ultra violet light and coal tar, while newer biological drugs alter the immune system to suppress psoriasis.

 

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psoriasis

Psoriasis is a common skin disease that causes raised red skin with thick silvery scales.

vitiligo

Vitiligo is a disorder in which white patches of skin appear on the body

hair loss

Hair loss usually develops gradually and may be patchy or diffuse

acne

Acne is a disorder of the hair follicles and sebaceous oil glands that leads to skin infections

dermatitis

Inflammation of the skin, often a rash, swelling, pain, itching, cracking. Can be caused by an irritant or allergen

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