General Approach to Treatment

© Management of patients with psoriasis generally involves both nonpharmacologic and pharmacologic therapies. Pharmacologic alternatives for plaque psoriasis include topical treatments, phototherapy, photochemotherapy, and systemic therapies alone (orally or by injection). The choice of treatment is usually dictated by the severity of disease.1 ,15 In some cases, a combination of treatment options may be preferred. Topical therapies can be used in patients with limited or mild to moderately severe disease. Phototherapy and photochemotherapy are used in moderate to severe disease. Systemic therapies are used for patients with extensive or moderate to severe disease. To minimize drug toxicities in these patients, systemic therapies are often used in rotation, or used in conjunction with topical or phototherapy.1 ,15 BRMs are becoming incorporated into the same category as other systemic agents and are currently recommended for consideration as first-line therapies alongside conventional systemic agents for moderate to severe disease.15 However, since there is a significant cost difference, biologic agents are often reserved for cases in which traditional systemic agents provide inadequate control or for patients with comorbidities (e.g., where traditional systemic agents may be inappropriate due to potential adverse effects). There are four recently published treatment guidelines including a 2008 guidelines of care for the management of psoriasis and psoriatic arthritis6 and a 2003 general consensus on psoriasis treatments, 4 both by the American Academy of Dermatology, a 2009 Canadian Guidelines for the Management of Plaque Psoriasis endorsed by the Canadian Dermatology Association at www.dermatology.ca/psoriasisguidelines.html and a consensus on moderate to severe psoriasis by the Canadian Psoriasis Expert Panel.15 In addition, it would be important to ensure appropriate screening and treatment of any

comorbid illnesses such as depression or diabetes, and to ensure appropriate management of symptoms such as itching.

Efficacy Assessment

Although there are tools to evaluate the efficacy of a psoriasis treatment, these are used primarily in clinical trials and rarely in clinical practice. These include the Psoriasis Area and Severity Index (PASI), the Physician's Global Assessment (PGA), and the National Psoriasis Foundation—Psoriasis Score (NPF-PS). The PASI is the most well known and measures the overall extent and severity of psoriasis, assessing areas of coverage, erythema, induration, and scaling. Clinical efficacy will be reported as a decrease in the PASI score, or an improvement (e.g., 75% improvement or PASI-75).6

In clinical practice, subjective qualitative assessments of disease severity is generally used to determine the efficacy of a treatment. In addition, an assessment of the patient's quality of life (QOL) is important in the management of psoriasis. The impact of psoriasis on a patient's psychological well-being may differ substantially from the severity of disease. Various QOL instruments validated for dermatologic diseases include the Dermatology Quality of Life Scales, Dermatology Life Quality Index (DLQI), Dermatology Specific Quality of Life Instrument, and Skindex-29.

Nonpharmacologic Treatment

® Nonpharmacologic alternatives may be extremely beneficial in the patient with psoriasis and complement pharmacologic therapies; thus should always be considered and initiated when appropriate. These include the following management strategies:10

• Stress reduction techniques. Psychotherapy including stress management, guided imagery, and relaxation techniques are being used more frequently as adjunctive therapies for patients with psoriasis. Stress reduction has been shown to improve both the extent and severity of psoriasis.

• Oatmeal baths. Regular use of oatmeal baths in tepid water may help soothe the itching associated with psoriasis and reduce the need for systemic antipruritic agents.

• Nonmedicated moisturizers. Maintaining adequate skin moisture helps to control the scaling associated with psoriasis. Emollients restore skin pliability, reduce skin

shedding, reduce pruritus, and help prevent painful cracking and bleeding. Non-medicated moisturizers may be liberally applied several times daily to help prevent skin dryness. Fragrance-free products should be selected when available.

• Avoid irritant chemicals on the skin. Harsh soaps or detergents should not be used. Cleansing should be done with tepid water, preferably using lipid-free and fragrance-free cleansers.

• Avoid skin trauma. Sunburns can induce a flare-up of psoriasis. Sunscreens with a sun protection factor of at least 15 should be routinely used when outdoors; often a sun protection factor of 30 is recommended. Avoid scratching the skin, which could lead to excoriations and exacerbate psoriasis. Loose-fitting cotton garments should be worn to minimize skin irritation.

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