Psoriasis is a difficult disease to treat. There are many topical and oral medications available. None of them can reliably clear the disease for long periods of time. Topical medications are safe when used appropriately. They are moderately effective and are best used in a rotational manner to avoid side effects. Many patients become discouraged with the time involved to apply creams and ointments. Patient’s often just give up and apply emollients. Applying topical medications once or twice a day over a wide area is inconvenient. Systemic medications should be considered for these patients.
All systemic medications have potential serious side effects. The patient and physician must weigh the risks and benefits of oral and subcutaneous delivered treatment.
There are several options for topical treatment. Topical medications work best when thick scale is removed first. This can be accomplished by soaking and removing scale or with salicylic acid preparations such as Keralyt.
Exposure to sunlight may be all that is necessary for the lucky patient who responds to ultraviolet light. Light therapy is available in many dermatologists offices. Patient’s often find it difficult to comply with the many office visits that are required. Home ultraviolet light machines are available and may be considered.
Tar Ointment has been used to treat psoriasis for over 100 years. This medication is available in the drug store without a prescription. There are many different brand names available. Some patients respond others do not. Tar and light therapy was the cornerstone of hospitalized treatment for many years. Patient’s were typically hospitalized for 3 weeks and most cleared. The practice of hospitalizing patient’s for this treatment was stopped because of the high cost involved.
Topical steroids are now the most commonly used treatment. These medications give very gratifying results initially but seemed to lose their effectiveness with repeated cycles of application. Treated areas may develop atrophy with long-term repetitive treatment. Clobetasol, the most potent topical steroid ever developed, is the topical steroid of first choice for most dermatologist. Clobetasol is available and creams, ointments, sprays, foams and lotions. The medication is applied once or twice a day for 7-30 days and then stopped. Care must be taken not to apply clobetasol to the face, under the arms, in the groin or around the anal area. Atrophy can develop rapidly in these areas. The longer the rest Off this medicine to better. Scalp psoriasis responds to clobetasol sprays, lotions, foams and shampoos.
Vitamin D. derivatives such as Dovonex and Vectical are safe, moderately effective topical medications that can be used as monotherapy or in combination with strong topical steroids. A typical program would be to apply Vectical twice each day during the week and a clobetasol preparation twice a day on Saturday and Sunday.
The emollients are an important part of treatment. Many patients will use these preparations as their only treatment. Heavy emollients such as Aquaphor for may be particularly soothing and effective. Patients with hand psoriasis report that these heavy emollients are quite comforting.
Anthralin and tazarotene have been used with some success. Anthralin stains and is messy. This medication is prescribed infrequently. Tazarotene is moderately effective but potentially irritating and is also now infrequently prescribed.
Methotrexate and cyclosporine are very effective oral medications. They are effective for all forms of psoriasis and psoriatic arthritis. They both the potential for causing serious side effects and many dermatologists do not feel comfortable using these drugs.
The new biologic agents are relatively safe, convenient and effective. They are delivered with auto injections by the patient. Enbrel, Humira and Stelara are 3 commonly prescribed biologic drugs. These medications cost over $20,000 a year.