Therapeutic options for psoriasis: Review and update

Psoriasis is a chronic skin condition that affects 2.6% of the population, or approximately 8 million people in the United States. Even though typical plaque-type psoriasis looks similar in different individuals, the way these individuals respond to various treatment modalities can be unpredictable. Moreover, even within the same person, it is not unusual for one lesion to respond to a treatment while another psoriatic plaque right next to it Fails to respond. Therefore, it is important to have as many treatment of options at one's disposal as possible to best meet the needs of psoriasis patients. The treatment options available can be roughly divided into three groups, namely tropical therapy, phototherapy and systemic medications. In addition, these treatment options can be used in various combinations to maximize the benefits and minimize the side effects. Also, fur those who need long-term maintenance therapy, these treatment options can be rotated form one to another to minimize the risk of long-term, cumulative side effects from any one treatment option. The topical treatments which can actually reverse the basic pathology of psoriasis include topical steroids, coal tar, anthralin and calcipottiene/calcipotriol. Modes of phototherapy include ultraviolet light B phototherapy or PUVA phototherapy. PUVA phototherapy can be applied either systemically or topically. The systemic agents available to treat psoriasis in the United States include acitretin, cyclosporin, hydroxyurea, sulfasalizine, and 6-thioguanine. Among these, the first three agents are known to be the most effective systemic agents in use. Generally, topical treatment are tried first and phototherapy next. Systemic medication are often reserved as a last choice because of the increased risk of systemic side effects,, both acute and long-term, cumulative. The new medications which have recently become available in the United States or which are expected to become available soon include Tazarotene gel, a topical modified vitamin A-type medication; Micanol, a less staining form of anthralin; Calcipotriene cream and scalp solution; Acitretin; and Neoral, a new formulation of cyclosporin with better and more reliable bioavailability. Lastly, despite the new medications which have become available over the years and the new research that is being conducted, the author's experience has been that no treatment works faster with fewer side effects and higher probability of long-term remission than the traditional Goeckerman/Ingram regimen in which the patient is coated in black tar and anthralin all day, every day (Monday through Friday) for several weeks, in addition to receiving outpatient UVB phototherapy. Unfortunately, in the United States, due to "tightening health care resources," this traditional Goeckerman therapy, which needs to be conducted in special centers, is slowly decreasing in availability. Therefore, in terms of actual patient care, it is not clear whether psoriasis therapy is going forward or backward in the United States.