Treatment of psoriasis. Literature review current through. Apr 2. 01. 7. Most cases are not severe enough to affect general health and are treated in the outpatient setting. Rare life- threatening presentations can occur that require intensive inpatient management. This topic reviews the treatment of psoriatic skin disease. The epidemiology, clinical manifestations, and diagnosis of psoriatic skin disease are discussed in detail separately, as are psoriatic arthritis and the management of psoriasis in pregnant women and special populations. Therefore, management of psoriasis involves addressing both psychosocial and physical aspects of the disease. Numerous topical and systemic therapies are available for the treatment of the cutaneous manifestations of psoriasis. Treatment modalities are chosen on the basis of disease severity, relevant comorbidities, patient preference (including cost and convenience), efficacy, and evaluation of individual patient response . Although medication safety plays an important role in treatment selection, this must be balanced by the risk of undertreatment of psoriasis, leading to inadequate clinical improvement and patient dissatisfaction . The clinician needs to be empathetic and spend adequate time with the patient. It may be helpful for the clinician to touch the patient when appropriate to communicate physically that the skin disorder is neither repulsive nor contagious. Clinicians should lay out reasonable aims of treatment, making it clear to the patient that the primary goal of treatment is control of the disease. Although treatment can provide patients with high degrees of disease improvement, there is no cure for psoriasis. Tonsillitis is an inflammation of the tonsils, the almond-shaped lymph nodes that hang down at both sides of the back of the throat – and it's very common in. Educating the patient about psoriasis is important and referral to an organization such as the National Psoriasis Foundation (www. Psoriasis may affect patients' perceptions of themselves and this can potentially initiate or exacerbate psychological disorders such as depression . Patients with limited skin disease may still have significant psychosocial disability . Some patients with psoriasis may benefit from counseling and/or treatment with psychoactive medications. Choice of therapy — For most patients, the initial decision point around therapy will be between topical and systemic therapy. However, even patients on systemic therapy will likely continue to need some topical agents. Planning and Tonsillectomy Recovery How long does it take to recover from getting your tonsils out? Instructions for Home Care After TONSILLECTOMY/ADENOIDECTOMY. SURGICAL DAY: Cool, clear liquids including water, Koolaid, Gatorade, ginger ale or other sodas. Topical therapy may provide symptomatic relief, minimize required doses of systemic medications, and may even be psychologically cathartic for some patients. For purposes of treatment planning, patients may be grouped into mild- to- moderate and moderate- to- severe disease categories. Limited, or mild- to- moderate, skin disease can often be managed with topical agents, while patients with moderate- to- severe disease may need phototherapy or systemic therapy. The location of the disease and the presence of psoriatic arthritis also affect the choice of therapy. Psoriasis of the hand, foot, or face can be debilitating functionally or socially and may deserve a more aggressive treatment approach. The treatment of psoriatic arthritis is discussed separately. Patients with more than 5 to 1. Attempts to treat extensive disease with topical agents are often met with failure, can add cost, and lead to frustration in the patient- clinician relationship. There is ample evidence of efficacy of the newer systemic therapies (. Established therapies such as methotrexate and phototherapy continue to play a role in the management of moderate to severe plaque psoriasis. However, the availability of biologic medications has reduced the challenge considerably. The concept that many patients with psoriasis in the United States do not receive sufficient treatment to control the disease is suggested by an analysis of surveys performed by the National Psoriasis Foundation between 2. Among the 5. 60. 4 survey respondents with psoriasis, 5. Many patients received no treatment, including 3. Further studies will be useful for clarifying the reasons for these observations and for determining the value of interventions to increase the accessibility of treatment. Widespread pustular disease requires aggressive treatment, which may include hospitalization.
Therapeutic approaches to generalized pustular psoriasis and psoriatic arthritis are discussed separately. Alternatives include vitamin D analogs, such as calcipotriene and calcitriol, tar, and topical retinoids (tazarotene). For facial or intertriginous areas, topical tacrolimus or pimecrolimus may be used as alternatives or as corticosteroid sparing agents, though improvement may not be as rapid. Localized phototherapy is another option for recalcitrant disease. Combinations of potent topical corticosteroids (table 1) and either calcipotriene, calcitriol, tazarotene, or UVB phototherapy are commonly prescribed by dermatologists. Calcipotriene in combination with Class I topical corticosteroids is highly effective for short- term control. Calcipotriene alone can then be used continuously and the combination with potent corticosteroids used intermittently (on weekends) for maintenance. A combination product containing calcipotriene and betamethasone dipropionate is available for this use. With proper adherence, considerable improvement with topical therapies may be seen in as little as one week, though several weeks may be required to demonstrate full benefits. Because adherence to topical treatment can be a major hurdle, keeping the treatment regimen simple and using treatment vehicles that the patient finds acceptable is often beneficial . Biologic agents used in the treatment of psoriasis include the anti- TNF agents adalimumab, etanercept, and infliximab, the anti- interleukin (IL)- 1. IL- 1. 7 antibody secukinumab. Improvement usually occurs within weeks. Patients with severe psoriasis generally require care by a dermatologist. Intertriginous psoriasis — Intertriginous (inverse) psoriasis should be treated with class VI and VII low potency corticosteroids (table 1) due to an increased risk of corticosteroid- induced cutaneous atrophy in the intertriginous areas. Topical calcipotriene or calcitriol and the topical calcineurin inhibitors tacrolimus or pimecrolimus are additional first- line treatments . These agents may be used alone or in combination with topical corticosteroids as corticosteroid sparing agents for long term maintenance therapy. Calcipotriene, tacrolimus, and pimecrolimus are more expensive options than topical corticosteroids. Some concerns have been raised about the safety of the calcineurin inhibitors (see 'Calcineurin inhibitors' below and . Scalp psoriasis — The presence of hair on the scalp can make topical treatment of psoriasis challenging because patients may find certain products messy or difficult to apply. Recognizing the patient's preference for a drug vehicle may help to improve adherence to therapy. For many patients, lotion, solution, gel, foam, or spray vehicles are preferable to thicker creams or ointments. Topical corticosteroids are the primary topical agents used for psoriasis on the scalp . Support for the use of these agents is evident in a systematic review of randomized trials that found that very potent or potent topical corticosteroids are more effective treatments for scalp psoriasis than topical vitamin D analogs . Combining a corticosteroid and vitamin D analog may offer additional benefit; in the systematic review, combination treatment with a potent topical corticosteroid and a vitamin D analog appeared slightly more effective than potent topical corticosteroid monotherapy. However, in clinical practice, complicating the treatment regimen with more than one topical product may reduce the likelihood of consistent adherence to the treatment regimen. Thus, we usually prescribe a topical corticosteroid alone as initial therapy. Commercial betamethasone dipropionate- calcipotriene combination products are available, but are more expensive than most topical corticosteroid preparations. Other topical therapies used for psoriasis (eg, tazarotene, coal tar shampoo, anthralin) and intralesional corticosteroid injections also may be beneficial for scalp involvement, though data on efficacy specifically in scalp disease are limited . Salicylic acid can be a helpful adjunctive treatment because of its keratolytic effect. Phototherapy (eg, excimer laser) and systemic agents are additional treatment options for patients who cannot achieve sufficient improvement with topical agents . Approaches include potent topical corticosteroids and topical bath psoralen plus UVA phototherapy (PUVA). However, these drugs appear to be particularly effective in the treatment of pustular psoriasis, and we consider them first line therapy. Acitretin is the retinoid that is used most often for this indication. Acitretin is a potent teratogen and should not be used in women who might become pregnant. Pregnancy is contraindicated for three years following acitretin therapy. The management of nail psoriasis is reviewed in detail separately. Based upon data from open- label or retrospective studies and case reports, a panel of experts suggested that patients with severe, unstable disease should be treated with cyclosporine or infliximab due to the rapid onset and high efficacy of these agents . Patients with less acute disease can be treated with acitretin or methotrexate as first- line agents. The panel advised against the use of systemic glucocorticoids due to the perceived potential for these drugs to induce a flare of psoriasis upon withdrawal of therapy. Etanercept was effective in an open- label study of 1. Topical therapies, such as mid- potency topical corticosteroids, emollients, wet dressings, and oatmeal baths can be used in concordance with systemic treatment to manage symptoms . Long- term maintenance therapy for psoriasis is required. Children — The immediate and long- term adverse effects of therapies for psoriasis are of particular concern in the pediatric population.
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