Psoriasis

Yes, psoriasis can be treated This six-part KULIT article series by the Persatuan Dermatologi Malaysia aims to raise awareness of psoriasis. In this final article, PDM President Dr Allan K C Yee highlights an important message for people with psoriasis – there is no cure yet for psoriasis, but its symptoms can be effectively treated and managed. Be open-minded and willing to work with your doctor to find a treatment that will work for you.

The object of treatment is to reduce the extent and severity of psoriasis – the red scaly stigmata, the tell-tale scaling on one’s clothes, the rough cracked palms that make handshakes awkward, painful joints that limit one’s activities. In short, the goal is to improve the quality of life which has been shown in studies to be as affected as much as other major diseases such as cancer, heart disease and depression. The good news is that with today’s medical armamentarium, much can be done to allow the sufferer a greatly improved quality of life.

Treatments must be individualized Fortunately, only 20% of psoriatics suffer from severe psoriasis, and the site involved is so variable that the treatments must be individualized. Limited disease can be treated with topical agents but more extensive skin involvement will require oral systemic treatments, phototherapy with artificial UV light, or even injectable agents (biologics). Furthermore psoriasis can affect any part of the body, each meriting special measures. Site-specific treatments For instance, thick scalp psoriasis is often mistakenly treated with endless anti-dandruff shampoos with little results.

Scalp psoriasis invariably responds dramatically to tar pomades under occlusion for one to two weeks, a tip that an experienced dermatologist would gladly share with sufferers. Similarly, thick and cracked scaly palms and soles that prevent working with the hands or sometimes even walking, can be significantly improved with special steroid-salicylic acid ointments used under occlusion. These soften and shed the thickened dead skin making the skin pliable and usable once more.

Psoriasis affecting the face, body creases – groins, armpits and private areas can be improved with the udicious use of weaker topical steroids and the newer and safer nonsteroidal calcineurin-inhibitors. The problem is that these thinned skinned areas are often treated with strong steroid creams that are not meant to be used in these sensitive areas. The end-result is irreversible side-effects such as ugly pink stretch marks, easy bruising and skin infections. We see a lot of these unfortunate cases who are sold these strong steroids from errant pharmacies without a prescription, or are introduced to them by well-meaning friends and relatives.

The Dermatological Society of Malaysia is working with the Ministry of Health to ensure that potent steroids are only available with a prescription. The treatment should not be worse than the disease! Hopefully with warnings such as in this article, the lay public will be better informed about the dangers of self-medicating with potent topical steroids. Topical Treatments Generally, when the extent of psoriasis is limited to less than 5 – 10% of the body surface area (BSA), it is best to use topical treatments in the form of creams, ointments, lotions.

As a guide, 1% of the BSA is the area covered by one’s palm. The red, thickened skin in psoriasis is due to the increased multiplication of the skin, allowing the collection of the dead skin layer to be manifested as thick scales. Most effective treatments whether topical or systemic work by reducing the cell multiplication, and by removing the dead skin layers. Time tested agents are coal tar, and anthranols which are messy and brown-staining thus adding further to the stigmatization sufferers feel.

More cosmetically acceptable topical agents are steroid creams, vitamin D analogues and calcineurin inhibitors. The latter two are more expensive than the ubiquitous steroid creams but with a superior safety profile. Most psoriatic lesions also tend to be dry and glycerin, urea-based or other humectant moisturizers help relieve soreness and improve recovery especially when used in conjunction with keratolytics – agents that soften and shed the abnormal dead skin layers. Systemic treatments When more than 10% of BSA is involved it becomes impractical to rely on topical measures alone.

It may take more than half an hour just to apply creams on large areas of affected skin. Hence, oral or injectable medications are required. Many of these drugs are able to reduce the skin’s cell multiplication or maturation rate eg methotrexate, hydroxyurea, retinoids. However many others suppress the disease process at a more fundamental level by suppressing the activity of abnormal white cells (T-cells) or by neutralizing the T-cells inflammatory chemicals (eg TNF a) eg cyclosporine and the newer biologic agents licensed for use in Malaysia.

With the proper use of these systemic agents singly or in combination, it is often possible to control even the most severe cases of psoriasis. However, these systemic agents should only be used by experienced physicians as many of them can have significant side effects. For example, persons with liver disease or gastric ulcers should not be treated with methotrexate; women of child-bearing age should not use retinoids as it can cause fetal abnormalities; persons with high blood pressure or kidney problems cannot use cyclosporine.

If a person with severe psoriasis has liver disease, is a woman of childbearing age, or has kidney problems what options then are available for him/her? There are 3 options – oral salazopyrine which only works in 50% of Asians, the injectable biologic agents, or phototherapy (see below). Biologic agents are the new kids on the block. They have a much better safety profile than the above mentioned oral drugs and can be used in persons with liver, kidney disease and women but unfortunately their high cost means relatively few can afford them.

Even in the west, where such expensive treatments are reimbursable, the psoriasis must be shown to be non-responsive to conventional oral drugs, or organ toxicities with these drugs are present. Some of them are very helpful in controlling psoriasis as well as the disabling arthritis that affects 10-30% of psoriatics. Phototherapy (PUVA, UVB, nUVB) This is an excellent form of treatment with artificial UV light which is relatively free from serious side effects apart from a small risk of developing non-melanoma skin cancers with prolonged use.

This risk is probably not significant in the setting of Asian skin types especially with the newer types of phototherapy equipment such as narrow band UVB (nUVB), and the excimer laser or excimer light. Another advantage of phototherapy is that it is a clean form of treatment, nonmessy and can give a long remission period of up to one year. The main drawback is that it does require visits to the phototherapy centre 3 times a week for 2-3 months. The good news is that most states in Malaysia now have phototherapy units to treat not only psoriasis, but also vitiligo and severe atopic eczema.

Alternative therapies In this day and age where the emphasis is on evidence-based medicine (EBM), alternative therapies must prove its worth with hard core scientific evidence from well-conducted clinical studies. Many people with psoriasis who have suffered from the condition for years are, not surprisingly, hopeful for answers, breakthroughs, and even a “cure” perhaps. Unfortunately, there is no shortage of charlatans offering “cures” for psoriasis, often in network marketing schemes.

One has to acknowledge the fact that psoriasis has a genetic basis, and unless gene therapy becomes a reality, there cannot be a cure, even with accepted treatments such as climatotherapy in the Dead Sea. Diets for psoriasis are as yet unproven, although an FDA-approved healthy diet with at least 5-9 servings of fresh preferably organic produce may be of help in improving one’s general health. Stress reduction strategies may help insofar as stress precipitates and aggravates psoriasis.

Prayer has been shown useful in several medical conditions, and a strong faith life can only help, if only to give one the equanimity to deal with the turbulence of modern life. The future of psoriasis treatments There is considerable optimism in the search for better and safer treatments for psoriasis in the near future. We now have a much better understanding of the genetics and underlying immune derangements in psoriasis. It is only a matter of time before the tremendous amount of ongoing research bears better fruit that is sweeter and without the bitter aftertaste of side-effects.

Indeed here are promising smaller molecules in the offing that are cheaper to synthesize. Watch out for this space. Psoriasis affects 2-3 percent of Malaysians. This is the final article of a six-part series from PDM’s “KULIT – Living with Psoriasis” Campaign 2007. For more on psoriasis, treatment options and KULIT, visit www. dermatology. org. my or email kulitcampaign@yahoo. com. This article is a guide to help you better understand psoriasis and psoriatic arthritis. Consult a suitably qualified medical practitioner before acting on any information contained above. KULIT is a community programme sponsored by Wyeth Malaysia.