Treatment of Psoriasis: An Algorithm-Based Approach for Primary Care PhysiciansSee related patient information handout on psoriasiswritten by the authors of this article. Psorisis is characterized by tren tay x100s, thickened plaques with a silvery scale. The lesions vary in size and degree of inflammation. Intralesional triamcinolone psoriasis is categorized as localized or generalized, based on the severity of the disease and intralesional triamcinolone psoriasis overall impact on the patient's quality of life and well-being. Patient education about the disease and the treatment options is important.
Update on intralesional steroid: focus on dermatoses. - PubMed - NCBI
See related patient information handout on psoriasis , written by the authors of this article. Psoriasis is characterized by red, thickened plaques with a silvery scale. The lesions vary in size and degree of inflammation. Psoriasis is categorized as localized or generalized, based on the severity of the disease and its overall impact on the patient's quality of life and well-being.
Patient education about the disease and the treatment options is important. Medical treatment for localized psoriasis begins with a combination of topical corticosteroids and coal tar or calcipotriene.
For lesions that are difficult to control with initial therapy, anthralin or tazarotene may be tried. The primary goal of therapy is to maintain control of the lesions. Cure is seldom achieved. If control becomes difficult or if psoriasis is generalized, the patient may benefit from phototherapy, systemic therapy and referral to a physician who specializes in the treatment of psoriasis. Psoriasis affects about 2 percent of the U.
In , psoriasis was the reason for more than 1 million visits to physicians. This article describes an algorithmic treatment approach for primary care physicians. The algorithm is based on treatment guidelines for psoriasis published by the American Academy of Dermatology, 3 supplemented by a review of the medical literature.
There currently are no evidence-based guidelines for the treatment of psoriasis. Because localized plaque psoriasis is the most common form, the algorithm focuses on the treatment of this type of psoriasis. The primary cause of psoriasis remains unknown. Abnormal epidermal cell kinetics and abnormal activation of immune mechanisms are thought to be the major contributors, and treatment may affect one or both of these mechanisms. The primary lesion is a well-demarcated erythematous plaque with a silvery scale.
Characteristically, psoriasis is symmetrically distributed, with lesions frequently located on the ears, elbows, knees, umbilicus, gluteal cleft and genitalia Figure 1. The joints psoriatic arthritis , nails and scalp may also be affected. Common areas of distribution of psoriasis. The lesions are usually symmetrically distributed and are characteristically located on the ears, elbows, knees, umbilicus, gluteal cleft and genitalia.
Itching is the most common symptom, 4 and extensive scratching can often lead to superimposed lichen simplex chronicus. In some patients, burning and pain may be the only symptoms. Psoriasis can be classified into four types: The less common forms of psoriasis include pustular localized and generalized and erythrodermic variants.
The most common form is plaque-type psoriasis Figure 2. The scale itself is variable, ranging from a thick, massive scale, as is generally seen on the scalp, to no scale at all, as is generally seen in intertriginous or partially treated areas. Atopic dermatitis, irritant dermatitis, cutaneous T-cell lymphoma, pityriasis rubra pilaris, seborrheic dermatitis.
Teardrop-shaped, pink to salmon, scaly plaques; usually on the trunk, with sparing of palms and soles. Erythematous papules or plaques studded with pustules; usually on palms or soles known as palmoplantar pustular psoriasis.
Same as localized with a more general involvement; may be associated with systemic symptoms such as fever, malaise and diarrhea; patient may or may not have had preexisting psoriasis. Severe, intense, generalized erythema and scaling covering entire body; often associated with systemic symptoms; may or may not have had preexisting psoriasis.
Drug eruption, eczematous dermatitis, mycosis fungoides, pityriasis rubra pilaris. A primary lesion of plaque-type psoriasis.
The typical lesion is a well-demarcated, thick, erythematous plaque with a silvery scale. Guttate psoriasis is characterized by numerous small, oval teardrop-shaped lesions that develop after an acute upper respiratory tract infection.
These lesions are often not as scaly or as red as the classic lesions of plaque-type psoriasis. Usually, guttate psoriasis must be differentiated from pityriasis rosea, another condition characterized by the sudden outbreak of red scaly lesions. Compared with pityriasis rosea, psoriatic lesions are thicker and scalier, and the lesions are not usually distributed along skin creases.
The diagnosis of psoriasis can usually be made on the basis of the clinical presentation; histologic confirmation is rarely needed. If the diagnosis is uncertain, a biopsy can be performed or consultation with a dermatologist can be obtained. Once the diagnosis of psoriasis is made, patient education about the disease should begin. Points that should be emphasized about the disease initially include its noncontagious nature and the possibility of controlling but not curing it.
Patients should also be assured that psoriasis is quite common. Exacerbating factors should be discussed, including stress, infection, trauma, xerosis and use of medications such as angiotensin-converting enzyme inhibitors, beta-adrenergic blockers, lithium and the antimalarial agent hydroxychloroquine Plaquenil.
The National Psoriasis Foundation is a widely used resource for patients Web site: An algorithm for the treatment of localized psoriasis is depicted in Figure 3.
Localized psoriasis can be defined as disease that is limited to such a degree that topical therapy controls it. Generalized psoriasis may require oral medications, treatment with ultraviolet light or treatment at an outpatient or inpatient facility. Algorithm for the treatment of localized psoriasis. Treatment of localized psoriasis is initiated using topical corticosteroids, alone or in combination with coal tar or calcipotriene.
Patients with resistant lesions may benefit from the addition of anthralin or tazarotene. The treatment of psoriasis requires an understanding of the effect that psoriasis is having on the patient's quality of life, and that effect is extremely variable.
Taking the individual patient's treatment needs into consideration can improve the overall outcome. Topical therapy, including corticosteroids, calcipotriene Dovonex , coal tar products, tazarotene Tazorac and anthralin Anthra-Derm , is the mainstay of treatment for localized disease Tables 2 and 3.
While the use of emollients should be encouraged, they should be used selectively because many e. Low-potency corticosteroids classes 6 and 7 , such as desonide Desowen , aclometasone dipropionate Aclovate ; hydrocortisone agents Cortizone, Cortaid, etc.
Medium-potency corticosteroids classes 3, 4 and 5 , such as triamcinolone acetonide Kenalog , hydrocortisone valerate Westcort , fluticasone propionate Cutivate , halcinonide Halog , mometasone furoate Elocon. High-potency corticosteroids classes 1 and 2 , such as halobetasol propionate Ultravate , clobetasol propionate Temovate , diflorasone diacetate Psorcon , betamethasone dipropionate Diprolene , clobetasole propionate Cormax.
Side effects increase with increased potency, duration of therapy and total dosage. For onycholysis, a topical corticosteroid in a solution vehicle may be used under the nail. Systemic therapy may be required to improve severe disease. The thin skin of the genitalia is highly sensitive to the adverse effects atrophy of topical corticosteroids. A low-potency topical corticosteroid ointment is recommended.
Topical calcipotriene, which is not associated with a risk of atrophy, may be used. The thick stratum corneum of palms and soles is a barrier to penetration of topical agents. A highest-potency topical corticosteroid is recommended. Methotrexate Rheumatrex or acitretin Soriatane; a systemic retinoic acid analog may be needed.
Topical corticosteroids are the most commonly prescribed treatment for psoriasis. Corticosteroids have well-recognized anti-inflammatory and antiproliferative effects, which are thought to be their primary mechanism of action in psoriasis.
In general, treatment is initiated with a medium-strength agent, and high-potency agents are reserved for the treatment of thick chronic plaques that are refractory to weaker steroids.
Low-potency agents are used on the face, on areas where the skin tends to be thinner, and on the groin and axillary areas, where natural occlusion increases the potency of a low-potency agent to the equivalent of a higher potency agent. Use of high-potency agents in these areas increases the risk of side effects and therefore should be avoided. Potential side effects from corticosteroids include cutaneous atrophy, telangiectasia and striae, acne eruption, glaucoma, hypothalamus-pituitary-adrenal axis suppression and, in children, growth retardation.
The true incidence of corticosteroid-induced hypothalamus-pituitary-adrenal suppression is unknown, but it is of concern with prolonged use. Careful long-term follow-up of patients receiving topical corticosteroid therapy is highly recommended to detect potential complications. Although corticosteroids are rapidly effective in the treatment of psoriasis, they are associated with a rapid flare-up of disease after discontinuation, and they have many potential side effects.
Consequently, topical corticosteroids are frequently used in conjunction with another agent to maintain control. Topical calcipotriene is often used in combination with topical corticosteroids to speed clearing of the lesions and maintain control after the initial phase of treatment is completed.
Calcipotriene is a vitamin D 3 analog available in cream, ointment and solution formulations. It inhibits epidermal cell proliferation and enhances normal keratinization. This agent has a slow onset of action, and patients should be aware that the effects of calcipotriene may not be noticeable for up to six to eight weeks after the initiation of therapy. Although calcipotriene monotherapy has been shown to be moderately effective in reducing the thickness, scaliness and erythema of psoriatic lesions, 8 maximal benefits are achieved when calcipotriene is used in combination with potent topical corticosteroids.
This second phase helps prevent rebound from abrupt withdrawal of corticosteroids. When the lesions have remained flat and the intensity of their color has declined from bright red to pink, the maintenance phase begins, with use of calcipotriene alone and discontinuation of the weekend use of topical corticosteroids.
After appropriate control of the disease is maintained, topical therapy can be discontinued until a flare-up occurs. Use of emollients should be recommended, to reduce the scaly appearance of the lesions and to potentially reduce the amount of corticosteroid needed. The only cutaneous side effect of calcipotriene is local irritation, which occurs in approximately 15 percent of patients.
Hypercalcemia is a potential side effect of this agent when the dosage exceeds g per week. This effect does not usually occur with weekly use of g or less. For localized psoriasis, the recommended dosages do not require monitoring of serum or urinary calcium levels. However, calcipotriene should be used with caution in patients with compromised renal function or a history of renal calculi.
Coal tar is a black viscous fluid that was first described by Goeckerman in , when it was combined with ultraviolet light for the treatment of psoriasis. It is thought to suppress epidermal DNA synthesis.
Coal tar is available as an ointment, cream, lotion, shampoo, bath oil and soap. Coal tar is most effective when it is used in combination with other agents, especially ultraviolet B light. Like calcipotriene, coal tar is effective when it is combined with topical corticosteroids.