Review Article
Management of Psoriasis
Aida J. Al-Kudwah, MD, and Steven R. Feldman,
Abstract: Psoriasis is common, affecting about 23% of the popu-
lation, and has major effects on patients quality of life. Psoriasis
varies in its manifestations and in how patients perceive the condi-
tion. Successful treatment involves addressing the clinical, psycho-
logical, and social aspects of the disease. Treatment options include
topical agents, phototherapy and systemic treatment. Topical treat-
ments are only practical for a fairly limited area of involvement.
Phototherapy is practical for larger areas of involvement, but office
phototherapy treatments are inconvenient. Traditional systemic med-
ications are limited by side effects. New biologic agents that target
specific components of the immune system are the most recent
addition to our list of medications and provide higher efficacy with
an improved safety profile, albeit at a higher cost.
Key Words: biologics, PASI score, phototherapy, quality of life,
systemic agents, topical therapy
S kin rashes do not commonly kill patients, but they may have
a large impact on patients quality of life.1 The impact of
psoriasis is as high as that of other major medical diseases.2
Psoriasis affects patients self image, social interactions and pro-
fessional life. More than cosmetic, psoriasis is associated with
pruritus, inflammation, arthritis, and psychiatric and cardiovas-
cular comorbidities.35 Psoriasis is chronic and unpredictable,
adding to patients frustration with the disease.6,7
An underlying T-helper cell dysregulation is believed to
be critical in the pathogenesis of psoriasis, but the actual
factor or factors that induce expression of psoriasis in genet-
ically susceptible patients is not known.8 10 Several histo-
compatibility antigens (HLA) have been linked to the differ-
ent variants of psoriasis, and recently, variant alleles of the
IL-23 receptor gene have been linked to psoriasis as well.1113
Psoriasis often affects the scalp, elbows and knees, but
any portion of the body surface can be affected. The disease may
From the Departments of Dermatology, Pathology, and Public Health Sci-
ences, Center for Dermatology Research, Wake Forest University School
of Medicine; Winston-Salem, NC.
Reprint requests to Steven R. Feldman, MD, PhD, Department of Dermatology,
Wake Forest University School of Medicine, Medical Center Boulevard,
Winston-Salem, NC 27157-1071. Email: sfeldman@wfubmc.edu
The Center for Dermatology Research is supported by an educational grant
from Galderma Laboratories, L.P.
Accepted February 13, 2009.
Copyright 2009 by The Southern Medical Association
0038-4348/02000/10200-0631
Southern Medical Journal Volume 102, Number 6, June 2009
MD, PhD
involve only a few spots or may involve extensive areas. Lesions
are typically thick and scaly, but variants may be thin and stud-
ded with pustules. There are numerous different treatment op-
tions available.14,15 Different patients may experience similar
lesions in very different ways and may have different prefer-
ences and concerns regarding treatment. Psoriasis treatment is
therefore individualized, taking into account these many factors,
to best fit a particular patients needs.
Clinical Features
Chronic plaque-type psoriasis is the most common form
of psoriasis (Fig. 1). Lesions consist of red, scaly, indurated
plaques, usually distributed symmetrically on the extensor
surfaces of the extremities.16 The scalp, lower back, buttocks,
umbilicus and the intergluteal cleft are other areas of predi-
lection. Area of involvement as well as the size of individual
lesions can vary considerably from a few millimeters to tens
of centimeters. Nails may be affected in different ways re-
flecting the part of the nail apparatus affected by the patho-
logical process. Onycholysis (separation of the nail from the
nail bed) is due to subungual hyperkeratosis, while pitting or
destruction of the nail plate is caused by involvement of the
nail matrix.17,18
Guttate psoriasis commonly affects children and young
adults. The word guttate refers to drop-like, and individual
lesions are usually less than 1 cm in diameter. They are
distributed on most of the skin surface, particularly the trunk.
The onset of this form of psoriasis may be associated with a
preceding streptococcal infection.19 Guttate psoriasis may re-
solve with an excellent long-term prognosis, though it may
also continue to run in a chronic course.20
Inverse psoriasis involves intertriginous areas, including
axillae, gluteal folds, and the submammary areas. Inverse
psoriasis is typically very red and glazed. It may be macer-
ated, particularly in obese patients.16
Erythrodermic psoriasis is a rare form of psoriasis in
which erythema with fine scaling affects nearly the entire
skin surface. The erythema is caused by generalized vasodi-
latation and can lead to hypothermia and high-output cardiac
failure. Impaired hepatic and renal function and marked pro-
tein loss, through scales shedding, can also occur. This vari-
ant may require hospitalization.16
There are two variants of pustular psoriasis. The first major
variant is localized pustular psoriasis and typically affects the
palms and/or soles. It is also called palmoplantar pustulosis or
631
Al-Kudwah and Feldman Management of Psoriasis
Fig. 1 Plaque psoriasis. Psoriasis plaques are generally red,
thick and scaly. The borders of the plaques are usually sharply
defined.
palmoplantar psoriasis (Fig. 2). A related form that affects the
fingers selectively is known as acrodermatitis continua of Hal-
lopeau. The other major variant is generalized pustular psoriasis,
a severe form of psoriasis that is sometimes associated with use
or withdrawal of systemic steroids.2123
Psoriatic arthropathy is a seronegative spondyloarthritis
present in about 15% of patients with psoriasis. Joint symp-
toms may precede the skin involvement, appear concomi-
tantly or, usually, appear at a later date. As skin disease often
appears first, it is important for physicians caring for patients
with psoriasis to screen for joint involvement and to educate
patients to be on the lookout for joint-related symptoms.
Histopathology
Despite its many variants and phenotypic expressions,
psoriasis has characteristic histopathologic features including hy-
perproliferation of epidermal keratinocytes (acanthosis), focal
accumulation of neutrophils and lymphocytes, foci of paraker-
atosis, papillary elongation, capillary dilatation (accounting for
the redness of the lesions) and a mononuclear inflammatory
infiltrate in the dermis. All forms of psoriasis are associated with
neutrophils in the stratum corneum; in pustular variants, the
accumulations of neutrophils in the stratum corneum are large
enough to be visible to the naked eye.23 Thus, while many
psoriasis treatments are tested in the common plaque variety,
they are used to treat all forms of psoriasis.
Psoriasis Management
The choice of treatment in psoriasis is complicated by
the wide spectrum of clinical presentations and by a wide
variety of potential treatment modalities (Table). The severity
of the clinical presentation and patients preferences are crit-
ical factors influencing the choice of treatment (Fig. 3). Pso-
632
Fig. 2 Palmoplantar psoriasis. The palmoplantar variant of
psoriasis can be particularly disabling. In addition to the usual
redness and scaliness seen in plaque psoriasis, palmoplantar
lesions are often associated with visible, painful pustules.
riasis treatments can be categorized into three major groups:
topically applied medications, phototherapy and systemic
medications. New biologic treatments, grouped with other
systemic treatments, have revolutionized the management of
severe psoriasis.24
The goal of psoriasis treatment is to bring the disease
under control with minimum morbidity and acceptable side
effects. Psoriasis management plans are tailored to fit pa-
tients individual needs, taking into account his/her expecta-
tions, perception of the severity of the disease, financial im-
plication and potential side effects. The principle of do no
harm must be balanced by the avoidance of inadequate treat-
ment, as psoriasis often has a major impact on patients qual-
ity of life.25
The first step is to address the patients psychosocial
issues. A thorough examination, including palpation of the
plaques with the bare hand helps communicate to patients that
they are not untouchable. Patients should be encouraged to
seek information at the National Psoriasis Foundation web-
site, www.psoriasis.org.26 The Foundation provides patients a
better insight into the disease, the available treatment options,
2009 Southern Medical Association
 Review Article

Table. Standard treatments for psoriasisa

Clinical
Modality indications Medication Advantages Side effects Comments
Topical medications Stable plaque-type Corticosteroids Fast acting, good response, Skin atrophy, striae, These meds can be used
psoriasis, BSA available in variety of tachyphylaxis, HPA axis on their own or in
10% vehicles, brand name, suppression combination with other
and generics available treatments
Vitamin D analogs No risk of atrophy Local irritation. Hypercalcemia Slow acting
with doses greater than
about 120 g/w
Phototherapy and Stable plaque-type UVB (broad band Very safe, low cost. Home Photodamage, photoallergic Keratolytics and acitretin
photochemotherapy psoriasis, BSA and narrow UV provides added rxns, some small risk of increase effectiveness
10% band) convenience skin aging, and cancer
PUVA Highly effective. No Increased risk of acute burns Requires ocular protection
internal toxicity with treatment and long- for 24 h after treatment.
term risk of skin cancer Acitretin increases
effectiveness
Systemic therapies Recalcitrant psoriasis Methotrexate Relatively safe and control Myelosuppression, hepatic, and Can be used individually
to topicals and is achieved at small pulmonary fibrosis, or in combination with
phototherapy, doses lymphoma, other agents. Alcohol
BSA 10% immunosuppression increases risk of hepatic
toxicity
Severe psoriasis Acitretin Suitable for male patients Acitretin: hepatotoxicity, lipid Adjunct to phototherapy
and females who are not abnormalities, teratogenicity, to increase efficacy. A
of child-bearing dose-dependent primary treatment for
potential mucocutaneous toxicity palmoplantar psoriasis
Severe psoriasis Cyclosporine Rapid clinical response Nephrotoxicity and For short-term treatment
hypertension only
Biologics Severe psoriasis and TNF inhibitors Good for joint disease TB reactivation, could No labs necessary except
psoriatic (etanercept, precipitate multiple sclerosis perhaps hepatitis
arthropathy infliximab, and theoretical risk of screening, self
adalimumab) lymphoma administered, every 24
wk. Injection site
reactions. Potential
infusion reactions with
infliximab
Severe psoriasis CD2-LFA3 Excellent safety profile Theoretical increased risk of CD4 monitoring. Need
blocker serious infections and office visits for
(alefacept) malignancies administering. Limited
long-term experience
Severe psoriasis ICAM1-LFA1 No hepatic or pulmonary Risk of serious infections and Full blood counts initially.
blocker toxicity theoretical risk of Protective vaccination
(efalizumab) malignancies. before instituting
Thrombocytopenia treatment. Self
administered. Rebound
observed in trials.
Limited long-term
experience
a
BSA, body surface area; HPA, hypothalamic-pituitary-adrenal; UVB, ultraviolet B light; UV, ultraviolet; RXNS, reactions; PUVA, psoralen and UVA; TNF,
tumor necrosis factor; TB, tuberculosis.

and information on how to manage psychosocial issues. Joining
the Foundation helps reduce many patients sense of isolation.6,7
The severity of the disease is a key issue for subsequent
treatment planning. In clinical trials, severity is assessed us-
ing quantitative, validated measures. For studies involving
patients with extensive disease (typically defined as disease
affecting 10% of the body surface area), the Psoriasis Area
and Severity Index (PASI) is used to quantify the severity of
the disease and its response to treatment.27 The PASI pro-
vides a weighted estimate of the redness, thickness and sca-
liness of the psoriasis plaques multiplied by the body surface
area (BSA) affected. Global evaluation scores (clear, almost
clear, mild, moderate and severe) may also be used. A quality
of life measure may also be incorporated to assess the extent
to which the disease and the treatment affect the patients
quality of life.
In clinical practice, however, simple assessment mea-
sures are used. Patients can be categorized as having local-

Southern Medical Journal Volume 102, Number 6, June 2009 633

Al-Kudwah and Feldman Management of Psoriasis

Address psychosocial issues, encourage use of fects, and when to expect improvement.28 Topical treatment
Psoriasis Foundation (www.psoriasis.org), screen for
psoriatic arthritis
is more difficult to use than taking a pill. Treatment adher-
ence is the key issue for psoriasis treatment success.
The first line treatment for localized psoriasis is a potent
Localized disease Generalized disease
topical corticosteroid such as clobetasol.24 Ointments have
traditionally been used because of their ability to moisturize
Topical Medications
corticosteroids
dry, scaly psoriasis plaques, but patients often dislike using
UVB phototherapy
vitamin D3 analogs
+/- ointment vehicles. Various other formulations are available to
calcineurin inhibitors
topical medications suit different areas of the body and different personal pref-
or acitretin
erences. The development of lighter, less messy vehicles
such as lotion, solution, foam, shampoo and spray also de-
liver the corticosteroid well and may be preferred by many
Systemic medications patients. After achieving a satisfactory clinical response, the
Methotrexate
No response Biologics daily or twice daily application is gradually reduced to a
Response PUVA frequency that maintains adequate control of the disease.
Tachyphylaxis (loss of effectiveness over time) may occur,
Consider poor but it is probably due to poor adherence rather than loss of
adherence to
treatment
response.29
Response
Vitamin D (and sometimes vitamin A) analogues can be
Taper gradually until weaned used with topical corticosteroids to achieve a faster response
off. Reuse as needed to achieve
similar clinical response
and to reduce the duration of corticosteroid use.30 Use of
occlusive dressing (such as a plastic wrap) may enhance pen-
Taper down gradually (or) etration and speed response, but it is important not to com-
use rotational approach to plicate treatment to the point that compliance is adversely
minimize incidence of
No response side effects affected. Older topical medications such as tar and anthralin
are effective,31 but they are used much less commonly be-
cause they are messy to use. Tar and anthralin are irritating
Cyclosporin, and should not be used in the acute phase of erythrodermic or
hydroxyurea,
mycophenolate mofetil pustular psoriasis as they may further worsen the disease.
Because topical calcineurin inhibitors are not associated with
Fig. 3 Psoriasis treatment algorithm. Step 1 for treatment of all the atrophogenic effects of corticosteroids, drugs such as top-
patients with psoriasis is to manage the associated psychosocial
ical tacrolimus (Protopic) or pimecrolimus (Elidel) can be
issues and to screen for potential comorbidities. Then, patients
with localized disease are treated with topical treatments. Pa-
used for the treatment of sensitive skin areas such as the face
tients with disease that is too extensive for topical treatment are and flexures.
first treated with phototherapy. If phototherapy is not effective,
systemic treatments are used.
Phototherapy
Ultraviolet light in the form of sunlight has been used as
ized psoriasis, for which topical treatments are used, or gen- a psoriasis treatment for centuries. Sunlight contains both
eralized psoriasis, for which phototherapy or systemic treatments ultraviolet B (UVB, the higher energy rays responsible for
are needed.28 Patients who can reasonably apply topicals to most sunburns) and ultraviolet A (UVA, lower energy rays
all their spots have localized disease. Patients who cant ap- associated with tanning) light.32 Ultraviolet B is a highly
ply topicals to all the spots require phototherapy or systemic effective, very safe treatment for psoriasis. It is generally
treatment. Typically, patients with more than about 510% administered in physicians offices, though home photother-
BSA or those who have palm or sole involvement need more apy devices are also available. Tanning beds can be tried if
than just topical treatment. Very global clinical assessments other forms of phototherapy are not accessible. The major
(doing well, doing poorly) may be used to follow patients risks of UVB phototherapy are sunburn reactions, photoag-
response to treatment. An estimate of affected BSA may be ing, and a small increased risk of skin cancer.3335 The major
used to justify use of expensive systemic treatment to payers. limitation to office phototherapy is cost and inconvenience,
limitations that can be circumvented through home photo-
Topical Psoriasis Treatments therapy treatment.
Topical treatment, when properly used, is an effective Photochemotherapy with ultraviolet A (UVA) following the
and safe approach for localized psoriasis. Patients should be ingestion or topical application of photosensitizers (psoralen and
educated about the medications, their benefits and side ef- ultraviolet light A PUVA) has been used when UVB alone is

634 2009 Southern Medical Association


not adequate. PUVA treatment is more effective than UVB alone,
but PUVA is associated with greater toxicity, including risks of
more severe burns and a greatly increased risk of skin cancer.
PUVA should not be done with a tanning bed because of the
potential for life-threatening burns.36
Phototherapy can be used for localized psoriasis as well.
The excimer laser is one option for delivering UV to localized
areas of psoriasis.37 Localized phototherapy can also be done
in the office or at home with other UVB emitting devices.
Systemic Psoriasis Treatments
The oral retinoid acitretin is a useful treatment for ex-
tensive psoriasis as well as for pustular and palmoplantar
psoriasis variants. Oral retinoids potentiate the effectiveness
of phototherapy.22 Most side effects of oral retinoids (dry
skin, dry mucous membranes and hair loss) are annoying and
can be avoided by dose reduction. The most serious side
effect of retinoids is their teratogenicity and therefore, they
should be avoided in women of child-bearing potential. Other
side effects include hepatic dysfunction and hyperlipidemia.
Methotrexate is one of the most commonly used sys-
temic medications in the treatment of psoriasis.38,39 Doses
range from about 10 to 30 mg once a week. Folic acid can be
given on other days to reduce the frequency of gastric and
other side effects.40 At the initiation of treatment a test dose
of 5 mg is given, and blood counts and liver function tests are
performed after one week to monitor for side effects. Doses
are increased weekly as needed with weekly laboratory mon-
itoring. Hepatic and pulmonary fibrosis are serious potential
long-term side effects. Concomitant alcohol ingestion promotes
hepatic toxicity. Once clinical response is achieved on a stable
dose, blood tests are done about every 4 8 weeks to maintain
vigilance of any hepatic and/or bone marrow toxicity.
Inhibition of immune function with cyclosporin A is a
highly effective treatment for psoriasis. Cyclosporine can be
used to achieve rapid improvement in psoriasis severity but is
not commonly used because of the potential for serious side
effects. Psoriasis tends to be a chronic condition, and chronic
suppression with cyclosporine can result in renal impairment.
Careful creatinine clearance and blood pressure monitoring
are essential. The frequency of squamous cell carcinoma
(SCC) is increased, dramatically so in patients who have
previously received extensive photochemotherapy.41,42
New biologic treatments, particularly tumor necrosis factor
alpha (TNF) inhibitors, have revolutionized the management of
severe psoriasis.43 45 Some of these medications are also very
effective treatments for psoriatic arthritis. Biologics vary con-
siderably in their use, efficacy and safety.27,46,47 Alefacept
(Amevive) may be the least effective of the biologics for psori-
asis, but it may also be the safest. Alefacept induces long lasting
remissions in some patients. The TNF inhibitorsetanercept
(Enbrel), infliximab (Remicade), and adalimumab (Humira)
are among the most effective treatments for both psoriasis and
Southern Medical Journal Volume 102, Number 6, June 2009
Review Article
psoriatic arthritis. Adalimumab was considerably more effective
than methotrexate in a head-to-head clinical trial.44 Cost is a
major factor limiting use of biologics, however. Risks of acti-
vation of tuberculosis, other infections and potential increased
risk of malignancy are other critical limitations.
Conclusion
Patients with psoriasis are frequently frustrated by their
disease, their lack of knowledge about the disease, and their
previous treatment experience. Psoriasis management begins
with addressing the patients psychosocial needs. It is impor-
tant to show empathy and compassion and to listen to the
frustration experienced by the patient. This must be done
even if it doesnt change the diagnosis or the prescribed treat-
ment. Using resources from the National Psoriasis Founda-
tion helps educate patients about their disease and helps them
learn to manage the psychosocial impact of the condition.26,6
Physicians should encourage patients to participate in their
management plan as a way to help encourage better treatment
adherence and compliance, the lack of which is probably the
most common cause of treatment failure. Screening for pso-
riatic arthritis should also be done at each visit.
For treatment purposes, psoriasis can usually be classi-
fied as either localized or generalized. Localized disease is
treated with topical treatments, while generalized involve-
ment is first treated with phototherapy, and if phototherapy is
not effective, then with systemic treatments. For patients with
localized disease, new, less messy vehicles have promoted
much better disease control. For patients with more extensive
involvement, phototherapy is nearly always accessible if
home phototherapy devices and tanning beds are considered
options.
New injectable biologicsbased on an improved under-
standing of the immune systemhave vastly improved our
ability to manage severe psoriasis. As further advances are
made in the immunopathogenesis of psoriasis, newer agents
will be developed. Selective antagonists of Th17 cells, IL-12
and IL-23 are under development. Others are sure to follow,
giving new hope to our patients with psoriasis.46 48
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