- Patients with psoriasis have a lifelong illness that may be very visible and emotionally distressing. There is a strong need for empathy and a caring attitude in interactions with these patients.
- Psoriasis is a T-lymphocyte—mediated inflammatory disease that results from a complex interplay between multiple genetic factors and environmental influences. Genetic predisposition coupled with some precipitating factor triggers an abnormal immune response, resulting in the initial psoriatic skin lesions. Keratinocyte proliferation is central to the clinical presentation of psoriasis.
- Diagnosis of psoriasis is usually based on recognition of the characteristic psoriatic lesion and not based on laboratory tests.
- Treatment goals for patients with psoriasis are to minimize signs such as plaques and scales, alleviate symptoms such as pruritus, reduce the frequency of flare-ups, ensure appropriate treatment of associated conditions such as psoriatic arthritis or clinical depression, and minimize treatment-related morbidity.
- Management of patients with psoriasis generally involves both nonpharmacologic and pharmacologic therapies.
- Nonpharmacologic alternatives such as stress reduction and the liberal use of moisturizers may be very beneficial and should always be considered and initiated when appropriate.
- Pharmacologic alternatives for psoriasis include topical agents, phototherapy, and systemic agents (both traditional agents and newer biologic response modifiers).
- In initiating pharmacologic treatment, the choice of therapy is generally guided by the severity of disease. Topical agents are appropriate for mild to moderate disease, while systemic agents are better choices for moderate to severe disease. Phototherapy or photochemotherapy are used for patients with moderate to severe psoriasis, generally when topical therapies alone are inadequate. Patient-specific concerns such as existing comorbid conditions (e.g., diabetes mellitus, hypertension, renal impairment, or hepatic disease) must also be taken into consideration in the choice of therapy. Once the disease is under control, therapy should be stepped down to the least potent, least toxic agent(s) that maintain control.
- Rotational therapy (i.e., rotating systemic drug interventions) is a means to minimize drug-associated toxicities. However, continuous treatment has replaced rotational or sequential therapy and is now the standard of care for many dermatologists.
- Some biologic response modifiers have proven efficacy for psoriasis; however, there are differences among these agents, including mechanism of action, duration of remission, and adverse-effect profile. In general, due to their immunomodulatory effects, risk of infection is increased with most of these agents. The use of live or live-attenuated vaccines during therapy is generally contraindicated. Currently, biologic response modifiers are often considered for patients with moderate to severe psoriasis when other systemic agents are inadequate or relatively contraindicated. It has also been recommended that biologic response modifiers be considered as first-line therapy, alongside conventional systemic agents, for patients with moderate to severe psoriasis; however, in practice, drug access due to cost considerations may be a limiting factor. They may be appropriate if comorbidities exist.
After reviewing this chapter the reader should be able to:
- 1. Discuss the etiology of psoriasis, including genetic and immune changes and predisposing factors.
- 2. Describe the pathophysiology of psoriasis, including the types of psoriasis.