Course Content
Ideal in Brief
Psoriasis is one of the oldest known skin disease, and the most common autoimmune disease that affects millions of Americans. Although there is no cure – there are several treatment options available to manage the symptoms. This program will address three main treatment categories, as well as, newer medications that have drastically impacted psoriatic treatment.
Pronounced pso-ri-a-sis (s?-`ri-?-s?s or sore-EYE-ah-sis), comes from the Greek word Psora (itching condition or being itchy) and Iasis (action, condition).1,2,3 The Bantam Medical Dictionary defines psoriasis as “a chronic skin disease in which itchy scaly red patches form on the elbows, forearms, knees, legs, scalp and other parts of the body”.4
Psoriasis is thought to be probably one of the oldest or longest known skin disease. Psoriasis was “covered up” for thousands of years – that is until Egyptian mummies were exhumed. Scholars believe symptoms of psoriasis is mentioned in historical texts, including the Bible. Tzaraat (encompassing word for skin disease) disease is likely the same as Psoriasis.5
It was Greek physician Hippocrates (between 460 – 377 BC) who first introduced knowledge in treating skin ailments.6 During this time, the disease had different names, such as, lepra, psora, alphos, and leichen. It was physician Galen (133 – 200 AD) who was the first to call it psoriasis and observed psoriasis as a skin disease through clinical observation.6
In 1776, after Joseph Jacob Plenck of Vienna, psoriasis became a part of medicinal literature as scaly or scale like diseases.5 It was the twentieth century that led to treatments based on evidence and effectiveness (not trial and error) for each person, due to recognition of the underlying mechanism by which psoriasis manifest itself.
In the early 1990’s, the Human Genome Project led to identifying the genes that determine psoriasis, and by 1998, biologic medications became the latest and most advanced stage for psoriasis research and treatments.6 Agents made from substances found in living cells that act on the body’s immune system (targeting overactive immune cells), thus treating psoriasis which cause the disease.6
The late twentieth century has made a huge approach to the perplexity of psoriasis. Worldwide there has been more than 10,000 pieces of literature on psoriatic dermatosis, which makes the disease one of the most examined in the last decade.5
Besides being one the oldest known skin disease, it is also the most challenging, complex and multifactorial disease encountered by health care professionals, including dermatologist. Also, it is the most common autoimmune disease in the United States.7
According to current studies, approximately 7.5 or 8 million (approximately 2.2% of the population) Americans have psoriasis, and according to the World Psoriasis Day Consortium, 125 million people worldwide (2 to 3% of the total population) have psoriasis.7
Psoriasis is an equal opportunistic disease – affecting both men and women (slightly more common among women than men).8 However, it is more prevalent in Caucasians (2.5%) compared to African Americans (1.3%), based on a study conducted in the United States.9 It is often diagnosed in adults (26 years the median age of onset), but can often appear between the ages of 15 and 25.7 Still, it can develop at any age. Infants and children (affecting girls more commonly than boys) can be born with the disease or develop it as they age. Approximately 10 -15% of new diagnoses begin in children younger than ten years.8
A calculated $11.25 billion annually is the total direct and indirect healthcare cost of psoriasis for patients, with 40% of the cost burden accounting for work loss.7 An average of 26 work days are missed a year, which is approximately 60% of patients.7
Psoriasis is not contagious or infectious, nor is it transmitted by external contact, or exposure or from an outcome of poor hygiene.10-11 Also, there is no known cure for this persistent, chronic inflammatory disease that can have a disfiguring and deforming affect, which can also affect a person’s mental health status due to consciousness, sadness, despair, low self-esteem and embarrassment.9,11,12 A 2010 study demonstrated that individuals with psoriasis are at greater risk of depression, thoughts of suicide, and anxiety.13
So, just how does this complexing disease develop? The etiology is not exactly known, but genetic predisposition, immunologic, and environmental factors are significant. If one parent has psoriasis – there is a ten percent chance of the child having psoriasis, and if both parents have psoriasis – there is a 50% chance.7 One of three people with psoriasis report having a relative with psoriasis.7 The gene locus (position of a gene on a chromosome) is determined – chromosome 6, and there are nine key psoriasis susceptibility genes that seems to be involved, which are designated PSORS (SORE-ESS) 1 through 9.14 The major determinant is PSORS 1, which probably accounts for 35 – 50% of heritability.14 Psoriasis is associated with certain human leukocyte antigen (HLA) alleles (a variant/mutation of a given gene), particularly human leukocyte antigen Cw6 (HLA-Cw6).8 Therefore, genetics and an overstimulated immune system is considered the two most significant contributing factors, in which treatment is targeted primarily at rapid cell reproduction, which is what happens with psoriasis. A skin disease stimulated by an abnormal immune system, causing inflammation and creating an increased growth cycle of immature skin cells, which starts below the skin’s surface.15
How does the immune system factor in and why is psoriasis considered an autoimmune disease or “T cell-mediated disease”? A person’s own immune system fails to function properly and the T lymphocyte or T-cell attacks healthy skin cells mistakenly.16 One type of white blood cell, the B-cell begins creating antibodies that destroy normal skin cells. The T-cell (epidermis infiltrated by many activated T-cells), another type of white blood cell begins overproducing (hyperactivity) a protein called cytokine (important in cell signaling). This overproduction appears to turn off a signal that controls the growth of skin cells.15
Let’s consider what happens with normal skin reproduction: skin cells are continuously being formed deep beneath the surface of the skin (epidermis). After about a month, these cells are pushed up to the surface, which is termed cell turnover.15 The cells then eventually die and slough off, revealing new skin cells. Psoriasis is characterized by changes in the life cycle of skin cells. A malfunctioning immune system signal cells to proliferate or grow too rapidly on the surface of the skin, in which cell turnover can occur in a matter of days.15 This proliferation causes excess skin cells (dead skin and white blood cells) that can’t slough off quickly enough and they accumulate on the surface and the skin form thick, scaly patches on the skin’s surface. Blood vessels increase their flow to the skin in an effort to nourish the skin, which cause redness or swelling. Classis symptoms include: reddened, inflamed patches (psoriatic plaques) of skin with a silvery, flaky layer of dead cells (build up) on the surface.15 Figure 1. depicts psoriasis skin life cycle.17
Figure 1.
Psoriasis can begin subtle, hardly noticeable, or as an overnight attack on the skin. Some people affected by psoriasis are so minimal that they don’t know they have the condition; whereas, others seem to be affected on all major surfaces of the skin and repeatedly seek medical intervention for alleviation, or at times so severe the person must be hospitalized for treatment.11,18
Nearly one quarter of people diagnosed with psoriasis are considered to have moderate to severe cases. The severity of psoriasis is measured by how psoriasis affects a person’s quality of life. The National Psoriasis Foundation defines severity as:7
- Mild – affecting less than 3% of the body
- Moderate – affecting 3 – 10% of the body
- Severe – affecting greater than 10% of the body
Psoriatic locations of the body include (psoriasis is often symmetrical, affecting both sides of the body):8,11,14
- Elbows
- Knees
- Legs
- Calves and thigh
- Scalp
- Lumbosacral (lower back) areas
- Face
- Hands
- Palms
- Feet/soles of the feet
- Fingernail/toenails
- Under the arms (armpits)
- Trunk
- Under the breast
- Upper pelvic bone area
- Soft tissues of the genitals
- Around the genitals (between the thigh and groin)
- Intergluteal clefts
- Entire body
- Joints
- Inside the mouth (not common)
Symptoms of psoriasis can be varying, just as the degree of severity. There are several types or forms of psoriasis. Table 1. includes the types, symptoms/description and comments.3,14,19,20 Typical symptoms of psoriasis include:16
- Scaly patches of thickened skin
- Dry, cracked skin that may bleed
- Thickened, pitted or ridged nails
- Itching, burning or soreness
- Stiff and swollen joints
Table 1. Psoriasis Types | ||
Types or forms | Symptoms/description | Comments |
Plaque Psoriasis | Areas of raised reddish patches that are covered with silvery-white (scales) patches of dead skin cells. Patches can appear anywhere on the body, but appear mostly on the knees, elbows, lower back, and scalp. Patches vary in size and can appear as separate patches or join together to cover a large area (geographical plaques because skin lesions resemble maps), as that of the back or chest. | Also known as psoriasis vulgaris, the most common form of psoriasis – making up about 90% of cases. Patches usually appear in the same areas on opposite sides of the body. May persist for long periods of time. |
Guttate Psoriasis | Drop pear-shaped spots that appear small and red, and are covered by a fine scale, and are not as thick as typical plaques. Usually found on the trunk arms, and legs, but can appear on the scalp, face, and ears or show up all over the skin. | Guttate, the Latin word meaning “drop”. Primary affects young adults and children. Guttate psoriasis often comes on suddenly after an illness. One to three weeks after a viral or bacterial (usually streptococcal/strep throat) respiratory or throat infection. Others include: tonsillitis, stress, injury to the skin or family history of psoriasis. Spots may disappear in a few weeks or months without treatment. May have a single outbreak or repeated episodes. |
Inverse Psoriasis | Patches usually appear as smooth and shiny bright-red inflamed areas without a scaly surface. Skin feels very sore. They occur in the folds of the skin, such as the armpits, groin, under the breast, and in other folds around the genitals and buttocks. | Subject to irritation by friction and sweating. Common in people who are overweight/obese. Fungal infections are a potential trigger Inverse psoriasis may be especially difficult to treat. |
Pustular Psoriasis | Patches of noninfectious and non-contagious white pus-filled blisters that are generalized or affect smaller areas of the skin, such as the hands, feet or fingertips. The blisters eventually dry, turn brown and form a scaly crust or peel off. | Primary seen in adults. It generally develops quickly, with pus-filled blisters appearing in just hours after the skin becomes red and tender. The blisters may come and go frequently. Generalized pustular psoriasis can cause fever, chills, severe itching and diarrhea. There are three types of pustular psoriasis:
|
Erythrodermic Psoriasis | The skin surface becomes scaly and red – it looks like it is burned. Most or the entire skin turns bright red with a peeling rash that can itch or burn intensely. The body is unable to regulate and maintain its normal temperature (98.6°F), and the individual gets very hot or cold, which may result in the inability to protect itself from disease. | Also called psoriatic exfoliative erythroderma. The least common type of psoriasis, and extremely dangerous. Approximately 20% of such cases evolve from psoriasis itself. If an individual look like they have erythrodermic psoriasis they should seek medical attention immediately. This sometimes-fatal form of psoriasis may be the result of volatile plaque psoriasis – especially if systemic treatment has been abruptly interrupted. |
Psoriatic arthritis (PsA) | Inflamed scaly skin, which cause pitted, discolored nails and swollen, painful joints that are typical of arthritis. Affects the hips, knees, spine (spondylitis), and sacroiliac joint (sacroilitis). Involves painful inflammation of the joints and surrounding connective tissue, that can occur at any joint, but more commonly the fingers and toes, which can result in dactylitis (sausage-shaped swelling of the fingers and toes). | Approximately 30% of individuals with psoriasis will develop PsA. In 75% of the cases, skin manifestations of psoriasis tend to occur before arthritic manifestations. Estimates on its prevalence among people with psoriasis range from 2 – 42%. About 80% of PsA individuals have psoriasis in the nails. Arthritic and skin flare-ups tend to occur simultaneously. Although PsA is not as debilitating as other form of arthritis, it can cause joint stiffness and progressive damage that in most serious cases may lead to permanent deformity. PsA often divided into five forms include:
|
Nail Psoriasis | Pitting scattered in groups across the fingernails and toenails, having abnormal growth and discoloration (white or yellowish spots). Also, long ridges may develop across and down the nail. | Psoriatic nails are linked to PsA. More than 50% of patients with psoriasis have abnormal changes in their nails, which may appear before other skin symptoms. In some cases, nail psoriasis is the only symptom. Prone to onychomycosis (nail fungus). |
Seborrheic Psoriasis | Red scaly patch areas on the scalp. Also, behind the ears, above the shoulder blade, in the groin or armpits, as well as, the center of the face. | May be especially difficult to treat. |
For a slide show of psoriasis types, please follow link: http://www.mayoclinic.org/diseases-conditions/psoriasis/multimedia/psoriasis-pictures/sls-20076486?s=8.
Active Learning
Take a moment to think about Humira, a biologic to treat psoriasis. What source do you think it comes from? (hint: Hum-i-ra). List other biologic agents you are familiar with. How does your list compare to the information provided in the program?
Not only are risk factors associated with psoriasis, but triggers as well. A trigger is anything that can potentiate a disease in people who are predisposed or cause certain symptoms to occur or exacerbate symptoms in an individual who already have a condition or disease.21 Psoriasis triggers include:13,14,15,19,22
- Stress – stress and psoriasis often coincide. Unfortunately, stress is a major trigger for a psoriasis outbreak. The stress can be in any form, whether emotional, physical or toxic. Research has suggested that stress can trigger specific immune factors associated with psoriasis flares. The brain perceives stressors to be all the same. This continual perception of stress attacks the immune system by altering the body’s production of stress hormones, which weaken the body’s natural defense against disease. It is important to attempt to live a reduced stress life as much as possible. Relaxation techniques and exercises have shown to be beneficial in relieving stress.
- Alcohol consumption – a 2010 study found that people with psoriasis tend to drink more alcohol, and another study from Brigham and Women’s Hospital saw an increase (associated with two to three drinks per week) in psoriasis in those that specifically drank non-light beer.
- Infection – infections caused by viruses, bacteria, or fungi (candida albicans) can trigger some forms of psoriasis; therefore, immediate treatment by a healthcare professional is imperative. Bacterial and viral infections include:
- Streptococcal infections in the upper respiratory tract
- Staphylococcal skin infections (Boils)
- Human Immunodeficiency Virus (HIV)
- Human Papillomaviruses (HPV), an uncommon strain called EV-HPV (not a virus strain that cause genital warts or cervical cancer). Although EV-HPV is not a direct cause, it may contribute to the continuation of psoriasis.
- Diet (food-related) – poor protein and toxemia, as well as, low-fiber and high-fiber diet. A theory is that psoriasis occurs when the liver is not functioning optimally, in which endotoxins (waste from within the body) enter the bloodstream; A buildup of endotoxins, along with inadequate bowel flora (more bad bacteria than good, or an imbalance of colonic bacteria). A diet low in fiber increases the level of endotoxin-producing bacteria. Also, some experts believe that psoriasis can result from improper utilization of fat in the body. Therefore, psoriatic individuals should avoid forms of fat, such as, alcohol, potato chips, chocolate, fish/chip, sausages, pizza, and too much Bar-B-Q.
- Smoking – toxin
- Skin cut or scrape, insect bite and the Koebner response – the Koebner response is a delayed response to skin injury, in which psoriatic lesions develop later nearby or at the affected area. An injury may include an insect bite, skin infection or inflammation, or even excessive scratching. It is important to use extra precautions with any activity that may cause skin injury, such as, wearing long sleeves, gloves, and using insect repellant (bug spray).
- Weather – although most people benefit from sunlight – there are those whose symptoms worsen with cold and dry climate (moisture is deprived from the skin). However, some people have photosensitive psoriasis, which actually improves in winter and worsens in summer when skin is exposed to sunlight, and a sunburn is a major risk for a flare-up, particularly due to the damage it can do the skin. If a sunburn occurs, apply aloe, so it will heal more quickly. It is important not to leave a sunburn untreated. Also, it is important to have a hat and sunscreen available always.
- Obesity – excess weight can make symptoms worse. A 2013 study in JAMA Dermatology found a link between a low-calorie diet and decreased flare-ups.
- Hormone changes – the severity of psoriasis may fluctuate with hormone changes. Scenario includes:
- Puberty and menopause – disease frequency peaks
- Pregnancy – if any change at all – symptoms are more likely to improve, than worsen.
- Postpartum period (after delivery of baby) – if any change at all – symptoms are more likely to worsen.
- Medications – several medications have shown to exacerbate or aggravate psoriasis. Some interfere with the body autoimmune response, and others may have psoriasis for the first time after taking certain types of medications (drug-induced). Medications include:
- Non-steroidal anti-inflammatory agents – (Indomethacin and Aspirin).
- Angiotensin-converting enzyme (ACE) Inhibitors – used to treat hypertension and heart conditions (Captopril)
- Beta-blockers – drugs used to treat angina, hypertension, abnormal heart rhythms, anxiety, hyperthyroidism, migraine prophylaxis, glaucoma.
- Calcium-channel blockers
- Lithium – treat bipolar disorder and other psychiatric disorders.
- Antimalaria medication – used to treat malaria (Chloroquine)
- Antifungals – (Terbinafine, Nystatin)
- Antihyperlipidemics – lipid-lowering agents
- Iodides
- Interleukins, interferons
- TNF inhibitors, such as, Remicade (Infliximab) and Humira (Adalimumab)
- Corticosteroids (steroids) – overuse or sudden withdrawal may worsen symptoms. Also, withdrawal of topical corticosteroids, due to the rebound effect.
- Progesterone – used in female hormone therapies
Disease risk that can occur from psoriasis include:16
- Other autoimmune diseases, such as, celiac, sclerosis, and Crohn’s (inflammatory bowel disease)
- Metabolic syndrome – aggregate conditions: hypertension, elevated insulin levels, and abnormal cholesterol levels, which increases risk of heart disease.
- Cardiovascular disease:
- risk of heart attack is almost three times greater than those without psoriasis.
- risk of irregular heartbeats and stroke
- some psoriasis treatments may cause abnormal cholesterol levels and increase the risk of atherosclerosis (hardening of the arteries).
- Diabetes Mellitus (Type 2 Diabetes)
- Certain eye conditions or disorders (conjunctivitis, blepharitis, and uveitis)
- Kidney disease
- Parkinson’s disease
Because psoriasis mimics other skin diseases, it can be difficult to diagnose, but in most cases, it is relatively straight forward. A health care professional, more likely a dermatologist will obtain a medical history (ask a series of questions) and perform a physical exam – examining the skin, scalp and nails. Usually in psoriasis, the examination will indicate a large number of dry skin cells, but without many signs of inflammation or infection. Sometimes specific changes in the nails are often indicative of psoriasis. For a conclusive or definitive diagnosis, a microscopic examination (skin biopsy) of tissue is examined to determine the exact type of psoriasis and to rule out other skin conditions.12,16,19
After a definitive diagnosis, the approach to treatment or not is based on type and severity. The psoriasis area severity index (PASI) is the most common tool or indicator for psoriasis.14 PASI assesses the lesion severity, and area affected and combines the two factors in a single score – zero (no disease) to 72 (maximal disease). Figure 2. Demonstrates the distribution of psoriasis severity.14
Figure 2.
While there is no cure, there are many treatment options. The three main categories are:
- Topical (applied to skin) – mild psoriasis
- Phototherapy (treatment using light) – moderate psoriasis
- Systemic (oral, injection or infusion) – severe psoriasis
Topical treatment is usually in the form of steroids or corticosteroids. Corticosteroids have anti-inflammatory properties and are classified based on their skin vasoconstrictive abilities. The weaker corticosteroids are used for thin-skinned and sensitive areas, such as the face, eyelids, armpit, buttock, perianal and warm moist areas as the groin or between skin folds, such as the breast.23 Corticosteroids have seven classifications – based on potency. Class I is the strongest (very potent) and seven being the weakest (least potent). Table 2. list corticosteroids used to treat psoriasis and drug potency.23,24
Table 2. Corticosteroids, Class, and Potency | ||
Name | Class | Potency |
Clobetasol propionate | Class I | Very/Super Potent |
Mometasone furoate | Class III | Upper Mid-Strength |
Triamcinolone (TMC) acetonide | Class III | Upper Mid-Strength |
Halobetasol propionate | Class I | Very/Super Potent |
Fluocinonide | Class II | High Potent |
Desoximetasone | Class II | High Potent |
Fluocinolone acetonide | Class IV | Mid-Strength |
Fluticasone propionate | Class III | Upper Mid-Strength |
Betamethasone dipropionate | Class III | Upper Mid-Strength |
Hydrocortisone valerate | Class V | Mid-Strength |
Hydrocortisone 2.5% or 1% over-the-counter | Class VII | Weak strength |
Aclolometasone dipropionate | Class VI | Low strength |
Non-steroidal topicals used to treat psoriasis include:16,19
- Calcipotriene – a synthetic vitamin D derivative that diminishes the growth of skin cells. It is used to treat mild to moderate psoriasis and can be used alone or in combination with other topical medications or phototherapy.
- Tazarotene – a vitamin A derivative that normalizes DNA activity in skin cells and may decrease inflammation. Tazarotene is not recommended in pregnant, breast-feeding or intended to become pregnant psoriasis patients.
- Pimecrolimus – a calcineurin inhibitor, which is believed to disrupt the activation of T-cells. This disruption reduces inflammation and plaque buildup. Pimecrolimus is especially useful for thin-skin areas where corticosteroids or retinoids are too irritating or may have harmful effects. This medication is not recommended for continuous or long-term use, due to potential increased risk of skin cancer and lymphoma.
- Anthralin (Dritho-Scalp, Drithocream, Micanol) – believed to normalize DNA activity in the skin cells. Also, it can remove scale, thus making the skin smoother. It can produce remission for months. However, it is recommended only for chronic or inactive psoriasis – not for acute or inflamed eruptions. Due to its irritating and staining potential, healthcare providers often recommend short-contact treatment. Also, individuals with kidney problems should use with caution.
Phototherapy is treatment that uses natural or artificial ultraviolet light (UVA) or (UVB) either alone or in combination with medications. Light forms include:16
- Sunlight
- UVB phototherapy
- Narrow band UVB therapy
- Goeckerman therapy
- Photochemotherapy or psoralen plus ultraviolet A (PUVA)
- Excimer laser
Treating severe psoriasis as mentioned can be administered orally, by injection or infusion. Systemic medications include:16,19,25
- Cyclosporine (Neoral, Sandimmune) – this class of medication (oral route) suppresses the certain immune factors and may be similar to Methotrexate (MTX) in effectiveness (all forms of psoriasis). It is the first-line or primary systemic drug used to treat adults with von zumbusch pustular psoriasis or erythrodermic psoriasis. Neoral is the most commonly used and it is effective within 8 – 12 weeks.
- Retinoids (Acitretin, Accutane) – an oral vitamin A-related medication used to reduce or control the production of skin cells or cell reproduction and that have anti-inflammatory properties. Acitretin is the drug of choice and may be particularly effective for pustular or erythrodermic psoriasis. It is typically for first-line therapy of chronic palmoplantar or pustular psoriasis. Also, it may be used in combination with other therapies to treat plaque psoriasis. Accutane is far less potent than Acitretin, but still may be effective in treating pustular psoriasis, and may be used with phototherapy. Again, vitamin A medications should be avoided in pregnant, breast-feeding or intended to become pregnant psoriasis patients.
- Methotrexate (MTX) – an antimetabolite of the antifolate type. It is used for psoriasis because it decreases the production of skin cells and suppresses inflammation. Its mechanism of action includes the “inhibition of T cell activation and suppression of intercellular adhesion molecule expression by T cells; selective down-regulation of B cells; increasing CD95 sensitivity of activated T cells, and inhibition of methyltransferase activity, leading to deactivation of enzyme activity relevant to immune system function”. Also, it inhibits the binding of interleukin 1-beta to its cell surface receptor. It is first-line systemic drug used to treat severe arthritis (it may slow the progression of psoriatic arthritis). Figure 3. is a chemical structure of MTX.25
Figure 3.
Biological Response Modifiers (Biologics) – a new class of medication that have been considered to have revolutionized the treatment of chronic diseases like psoriasis. Biologics are not derived from plants or chemicals, but are made from sugars, proteins, nucleic acids or derived from human, animal or microorganism cells and tissues through the process of genetic engineering (biotechnology from their manufacture).19,26,27 The biologics listed in table 3. are not first-generation products, but rather second generation – that have been on the market for approximately 10 to 15 years.26,28,29 Biologics work by:28
- Suppressing T-cells directly
- Blocking interactions between certain immune system cells (a substance called tumor necrosis factor-alpha (TNF-alpha)), one of the main messenger chemicals in the immune system
- Blocking interleukins (immune system’s chemical messenger).
- Blocking particular inflammatory pathways (binding to proteins that cause inflammation).
Biologics interference with TNF-alpha or T-cells or by targeting interleukins disrupt the unhealthy association. Therefore, the symptoms of psoriasis (inflammation, overgrowth of thick, scaly skin) are reduced. Overall, biologics work well in many individuals. In clinical trials, the medications reduced psoriasis activity by 75%.28 Nevertheless, even though they are safe for most, close monitoring is necessary due to increased risk of infection, cancer and other complications. Also, because biologics are very costly, they are usually used for individuals who have failed to respond to traditional therapy or who have associated psoriatic arthritis. Figure 4. is a structure of Humira (a biologic).30
Table 3. Second generation biologics | ||
Name (brand and generic) | Classification | Route of administration |
Humira (Adalimumab) | TNF-alpha blocking antibody | Injection (subcutaneous) |
Amjevita (Adalimumab-atto) – biosimilar to Humira | TNF-alpha blocking antibody | Injection (subcutaneous) |
Enbrel (Etanercept) | TNF- alpha blocker | Injection (subcutaneous) |
Erelzi (Etanercept-szzs) – biosimilar to Enbrel | TNF- alpha blocker | Injection (subcutaneous) |
Remicade (Infiximab) | TNF- alpha blocker | Infusion (intravenous) |
Taltz (Ixekizumab) | Antibody that binds to inflammation-causing proteins/interleukins | Injection (subcutaneous) |
Cosentyx (Secukinumab) | Human antibody against interleukins | Injection (subcutaneous) |
Stelara (Ustekinumab) | Human antibody against interleukins | Injection or Infusion (subcutaneous/intravenous) |
Another class of medication used orally to treat psoriatic arthritis is Otezla (Apremilast). Otezla is not a biologic, but a phosphodiesterase-4 inhibitor (PDE-4). PDE-4 is an enzyme that controls inflammation within a cell.28
Even though there are several and a variety of treatment options (alone or concurrent) to manage psoriasis – research is still a long way from treatment possibilities and a cure. Which means, psoriatic patients are still affected and challenged with day to day living both physically and psychologically. Which is why support groups are beneficial and should be considered.
This year, 2017 is very significant for the National Psoriasis Foundation (NPF). NPF celebrates 50 years of patient support, advocacy, research funding, education and outreach.31 Officially becoming the National Psoriasis Foundation in 1967, whose mission is to focus on driving efforts to cure psoriatic disease.
Accomplishments NPF has made throughout its 50 years include:31
- Becoming the world’s leading nonprofit patient advocacy organization fighting for individuals with psoriasis and psoriatic arthritis.
- Significant contributions in advancing the research of life-changing treatments. From tar-based procedures and topical creams to the revolutionary biologic treatments of today.
- Support innovative approaches to treating psoriasis and psoriatic arthritis.
- Securing for the first time ever, line-item funding in a federal budget for skin disease research.
- Successfully lobbying the United States Food and Drug Administration (FDA) for the approval of MTX for the treatment of severe psoriasis.
- Opening the world’s first support center providing free personalized assistance for people with psoriatic disease.
- Members of the NPF medical board issued the first paper in the United States that outlines psoriasis treatment targets and goals for individuals and health care providers to work on together to achieve clear skin and ultimately reduce the challenge of the disease (most recent).
Remaining true to the 1967 mission, the theme of NPF 50th year celebration is “Driving Discovery, Creating Community”.31 The theme allows NPF to celebrate the achievements of the past 50 years, as well as, recognize the individuals and milestones that have made significant contributions to the psoriatic disease community.31 For more information on the NPF 50th celebration visit: https://www.psoriasis.org/NPF50th.
As pharmacy professionals, it is imperative to familiarize and understand psoriasis, which means treatment options used to manage the disease, particularly pharmaceuticals, there side effects, and contraindications. Pharmacy plays a very important role in integrative medicine, which takes into consideration the individuals physical, emotional, and psychological needs.
References:
1. “Definition of psoriasis.” Psoriasis | Definition of Psoriasis by Merriam-Webster, www.merriam-webster.com/dictionary/psoriasis. Accessed 6 Feb. 2017.
2. “The word psoriasis is derived from the Greek word Psora and Iasis.”The word psoriasis is derived from the Greek word Psora and Iasis – Psoriasis Treatments, peacelogs.com/the-word-psoriasis-is-derived-from-the -greek-word-psora-and-iasis/. Accessed 7 Feb. 2017.
3. “Psoriasis.” Psoriasis – Pariser Dermatology, 2014, pariserderm.com/services/common-concerns/psoriasis/. Accessed 9 Mar. 2017.
4. The Bantam Medical Dictionary. New York, NY, Bantam Books, 1990.
5. “History of Psoriasis.” Psoriasis Guide | History of Psoriasis, 2017, psoriasis.bafree.net/history-of-psoriasis.php. Accessed 7 Feb. 2017.
6. Seiden, Ellen. “The History of Psoriasis.” The History of Psoriasis |– National Psoriasis Foundation, National Psoriasis Foundation, 2016, www.psoriasis.org/advance/history-psoriasis. Accessed 6 Feb. 2017.
7. “Statistics About Psoriasis.” Psoriasis Statistics, MG217, 2017, www.mg217.com/your-psoriasis/statistics-about-psoriasis/. Accessed 7 Feb. 2017.
8. Meffert, Jeffrey. “Psoriasis.” Psoriasis: Practice Essentials, Background, Pathophysiology, Medscape, 7 Nov. 2016, emedicine.medscape.com/article/1943419-overview. Accessed 7 Feb. 2017.
9. “Medical Psoriasis.” Psoriasis Inflammatory skin condition, Dermsa, 2014, www.dermsa.com/content/medical/psoriasis/. Accessed 17 Feb. 2017.
10. Aguirre, Claudia C. “The Biology Behind Eczema and Psoriasis.” The Biology Behind Eczema and Psoriasis, Skin Inc, 29 June 2012, www.skininc.com/skinscience/physiology/160864185.html. Accessed 10 Feb. 2017.
11. Kumar, Rajnish, et al. “An Overview of Psoriasis with Respect to its Protein Targets.” Egyptian Dermatology Online Journal, vol. 6, no. 1, ser. 1, 30 May 2010, pp. 1–13. 1, www.edoj.org.eg. Accessed 7 Feb. 2017.
12. “Where Does Psoriasis Start?” Where Does Psoriasis Start? FavoritePlus, 17 Aug. 2012, www.favoriteplus.com/blog/psoriasis-start/. Accessed 6 Feb. 2017.
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