Biologics – Psoriasis

Life – Terror. Ecstasy. Fight. Denial. Flight. Failure. PAIN. Forgiveness. Reconciliation. Hope. Love. Peace – Death.

Psoriasis Treatments – aim to stop skin cells from growing so quickly and to remove scales. Options include creams and ointments (topical therapy), light therapy (phototherapy), and oral or injected medications.

Coping with psoriasis can be a challenge, especially if the affected skin covers a large area of your body or is visible to other people. It can cause discomfort and embarrassment. The ongoing, persistent nature of the disease and the treatment challenges only add to the burden.

Treatment Considerations

You and your consultant should negotiate a treatment approach based on your needs and the type and severity of your psoriasis. If an NHS patient this will also depend upon costs. You’ll likely start with the mildest treatments — topical creams and ultraviolet light therapy (phototherapy). Then, if your condition doesn’t improve, you move on to stronger treatments.

I recommend requesting a Biopsy as early as possible. Identification of exactly what type of psoriasis you have. People with pustular or erythrodermic psoriasis usually need to start with stronger (systemic) medications. In any situation, the goal is to find the most effective way to slow cell turnover with the fewest possible side effects.

Which treatments you use depends on how severe the psoriasis is and how responsive it has been to previous treatment and self-care measures. If you have ‘other’ serious conditions (cancer), some treatments are avoided or even ruled out completely. You might need to try different drugs or a combination of treatments before you find an approach that works. Even with successful (temporary) treatment, usually the disease returns and often more severely.

Biologics – These drugs, usually administered by injection, alter the immune system in a way that disrupts the disease cycle and (can) improve symptoms and signs of disease within weeks. Several of these drugs are approved for the treatment of moderate to severe psoriasis in people who haven’t responded to first line therapies.

Options include apremilast (Otezla), etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), ustekinumab (Stelara), secukinumab (Cosentyx), ixekizumab (Taltz), guselkumab (Tremfya), tildrakizumab (Ilumya) and certolizumab (Cimzia).

Three of them — etanercept, ixekizumab and ustekinumab — are approved for children. These types of drugs are expensive and may or may not be easily available. Biologics must be used with caution because they carry the risk of suppressing the immune system in ways that increase the risk of serious infections.

People taking these treatments must be screened for tuberculosis.

Topical therapies – Corticosteroids,  these drugs are the most frequently prescribed medications for treating mild to moderate psoriasis. They are available as oils, ointments, creams, lotions, gels, foams, sprays and shampoos. Mild corticosteroid ointments (hydrocortisone) are usually recommended for sensitive areas, such as the face or skin folds, and for treating widespread patches. Topical corticosteroids might be applied once a day during flares, and on alternate days or weekends during remission.

Your health care provider may prescribe a stronger corticosteroid cream or ointment — triamcinolone (Trianex) or clobetasol (Cormax, Temovate, others) — for smaller, less-sensitive or tougher-to-treat areas. Long-term use or overuse of strong corticosteroids can thin the skin. Over time, topical corticosteroids may stop working. Due to the ‘messy’ nature of many such ointments/creams/cold tar treatments it is sometimes necessary for hospitalisation to manage such applications.

Vitamin D analogues, synthetic forms of vitamin D — such as calcipotriene (Dovonex, Sorilux) and calcitriol (Vectical) — slow skin cell growth. This type of drug may be used alone or with topical corticosteroids. Calcitriol may cause less irritation in sensitive areas. Calcipotriene and calcitriol are usually more expensive than topical corticosteroids.

Retinoids,  Tazarotene (Tazorac, Avage, others) is available as a gel or cream. It’s applied once or twice daily. Tazarotene isn’t recommended when you’re pregnant or breastfeeding or if you intend to become pregnant.

Calcineurin inhibitors, calcineurin inhibitors — such as tacrolimus (Protopic) and pimecrolimus (Elidel) — calm the rash and reduce scaly buildup. They can be especially helpful in areas of thin skin, such as around the eyes, where steroid creams or retinoids are irritating or harmful. Calcineurin inhibitors aren’t recommended when you’re pregnant or breastfeeding or if you intend to become pregnant. This drug is also not intended for long-term use because of a potential increased risk of skin cancer and lymphoma.

Salicylic acid, salicylic acid shampoos and scalp solutions reduce the scaling of scalp psoriasis. They are available in non-prescription or prescription strengths. This type of product may be used alone or with other topical therapy, as it prepares the scalp to absorb the medication more easily.

Coal tar, coal tar reduces scaling, itching and inflammation. It’s available in non-prescription and prescription strengths. It comes in various forms, such as shampoo, cream and oil. These products can irritate or even burn ‘normal’ skin, careful application is required. They’re also messy, stain clothing and bedding, and can have a strong odour, an extremely nostalgic feeling for myself, reminiscent of hot summer days, as a child ‘playing out’ in the 60’s, bursting ‘Tar Bubbles’.

Anthralin – Anthralin is a tar cream that slows skin cell growth. It can also remove scales and make skin smoother. It’s not intended for use on the face or genitals. Anthralin can irritate skin, and it stains almost anything it touches. It’s usually applied for a short time and then washed off.

Light therapies

Light therapy is a first line treatment for moderate to severe psoriasis, either alone or in combination with medications. It involves exposing the skin to controlled amounts of natural or artificial light. Repeated treatments are necessary, often daily over a sustained period, short bursts for up to a month-to six weeks and clearly disruptive especially if you are working.

Sunlight, brief, daily exposures to sunlight (heliotherapy) might improve psoriasis. Not always possible, clearly dependent upon where you live in the world?

Goeckerman therapy,  an approach that combines coal tar treatment with light therapy is called the Goeckerman therapy. This can be more effective because coal tar makes skin more responsive to ultraviolet B (UVB) light.

UVB broadband, controlled doses of UVB broadband light from an artificial light source can treat single psoriasis patches, widespread psoriasis and psoriasis that doesn’t improve with topical treatments. Short-term side effects might include inflamed, itchy, dry skin.

UVB narrowband, UVB narrowband light therapy might be more effective than UVB broadband treatment. In many places it has replaced broadband therapy. It’s usually administered two or three times a week until the skin improves and then less frequently for maintenance therapy. But narrowband UVB phototherapy may cause more-severe side effects than UVB broadband.

Psoralen plus ultraviolet A (PUVA), this treatment involves taking a light-sensitizing medication (psoralen) before exposing the affected skin to UVA light. A 15-20 minute pre exposure bath (take your own duck). UVA light penetrates deeper into the skin than does UVB light, and psoralen makes the skin more responsive to UVA exposure.

This more aggressive treatment consistently improves skin and is often used for more-severe psoriasis. Short-term side effects might include nausea, headache, burning and itching. Possible long-term side effects include dry and wrinkled skin, freckles, increased sun sensitivity, and increased risk of skin cancer, including melanoma.

Excimer laser, with this form of light therapy, a strong UVB light targets only the affected skin. Excimer laser therapy requires fewer sessions than does traditional phototherapy because more-powerful UVB light is used. Side effects might include inflammation and blistering.

Money matters – oral or injected medications

If you have moderate to severe psoriasis, and or if other front line treatments haven’t worked, your health care provider may prescribe (expensive) oral or injected (systemic) drugs. Some of these drugs are used for only brief periods and might be alternated with other treatments because they have potential for severe side effects.

Steroids – pills, creams ointments can be applied but not longer term. If you have a few small, persistent psoriasis patches, your health care provider might suggest an injection of triamcinolone right into them. Retinoids – Acitretin and other retinoids are pills used to reduce the production of skin cells. After all frontline options are ruled out (often by trial and error) expensive Biologic treatments are the only (next) option. In the UK, under the NHS a patient has to have exhausted, at least 4-5 frontline options in order to progress to consideration for Biologics.

Biologics – These drugs, usually administered by injection, alter the immune system in a way that disrupts the disease cycle and improves symptoms and signs of disease, sometimes within weeks. These drugs are approved for the treatment of moderate to severe psoriasis in people who haven’t responded to first line therapies. They are not cheap and your consultant will have to fight your corner to access them.

Options include apremilast (Otezla), etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), ustekinumab (Stelara), secukinumab (Cosentyx), ixekizumab (Taltz), guselkumab (Tremfya), tildrakizumab (Ilumya) and certolizumab (Cimzia). Three of them — etanercept, ixekizumab and ustekinumab — are approved for children. These types of drugs are expensive, for example a shot of Stelara (my current treatment), is £2,147 (a £15K+ a year treatment).

Biologics must be used with caution because they carry the risk of suppressing the immune system in ways that increase the risk of serious infections. People taking these treatments must be screened for tuberculosis. People with cancer and other immune system affected diseases, ideally, should not take Biologics.

Methotrexate, usually administered weekly as a single oral dose, methotrexate (Trexall) decreases the production of skin cells and suppresses inflammation. It’s less effective than adalimumab and infliximab. It might cause upset stomach, loss of appetite and fatigue. People taking methotrexate long-term need ongoing testing to monitor their blood counts and liver function. People need to stop taking methotrexate at least three months before attempting to conceive. This drug is not recommended for those who are breastfeeding.

Cyclosporine, taken orally for severe psoriasis, cyclosporine (Gengraf, Neoral, Sandimmune) suppresses the immune system. It’s similar to methotrexate in effectiveness but cannot be used continuously for more than a year. Like other immunosuppressant drugs, cyclosporine increases the risk of infection and other health problems, including cancer. People taking cyclosporine long-term need ongoing testing to monitor their blood pressure and kidney function.

Other medications –  Thioguanine (Tabloid) and hydroxyurea (Droxia, Hydrea) are medications that can be used when you can’t take other drugs.

Alternative medicines – If it works it works?

Some studies claim that alternative therapies (integrative medicine) — products and practices not part of conventional medical care or that developed outside of traditional Western practice — ease and treat the symptoms and triggers of psoriasis.

Examples of alternative therapies used by people with psoriasis include special diets, vitamins, acupuncture and herbal products applied to the skin. Some of these approaches are backed by strong research evidence, they are generally safe and might help reduce itching and scaling in people with mild to moderate psoriasis but are not largely accepted within western medicine practise.

Aloe extract cream, taken from the leaves of the aloe vera plant, aloe extract cream may reduce scaling, itching and inflammation. Fish oil supplements, oral fish oil therapy used in combination with UVB therapy might reduce the extent of the rash. Applying fish oil to the affected skin and covering it with a dressing for six hours a day for four weeks might improve scaling. Good luck with socialising smelling like a smoked haddock! Oregon grape — also known as barberry — is applied to the skin and may reduce the severity of psoriasis. If you’re considering alternative medicine to ease the signs and symptoms of psoriasis, do your research and discuss with your health care provider about the pros and cons of these approaches.

Psoriasis Management

Take daily baths, wash gently rather than scrubbing your skin in the shower or bath. Use lukewarm water and mild soaps that have added oils or fats. It might help to add bath oil, Epsom salts or oatmeal to bathwater and soak for at least 15 minutes.

Keep your skin moist, apply moisturizer daily. If you’re moisturizing after bathing, gently pat dry and apply your preferred product while your skin is still moist. For very dry skin, oils or heavy ointment-based moisturizers may be preferable — they stay on the skin longer than creams or lotions do. If moisturizing seems to improve your skin, apply the product more than once a day. If the air where you live is very dry, use a humidifier to add moisture to the air.

In severe times, cover the affected areas overnight, before going to bed, apply an ointment-based moisturizer (Vaseline/Petroleum Jelly) to the affected skin and wrap with plastic wrap. I used plastic bags on my hands and feet. When you wake, remove the plastic and wash (shower) away scales.

Expose your skin to small amounts of sunlight, use natural sunlight to treat your skin. A controlled amount of sunlight can improve psoriasis, but too much sun can trigger or worsen outbreaks and increase the risk of skin cancer. Log your time in the sun, and protect skin that isn’t affected by psoriasis with a hat, clothing or sunscreen with a sun protection factor (SPF) of at least 30.

Avoid scratching, it might help to apply a non-prescription anti-itch cream or ointment containing hydrocortisone or salicylic acid. If you have scalp psoriasis, try a medicated shampoo that contains coal tar. Keep your nails trimmed so that they won’t hurt your skin if you do scratch. Wear soft fabrics that don’t contribute to itchiness. Good luck with that one people!

Avoid psoriasis triggers, notice what triggers your psoriasis, and take steps to prevent or avoid it. Infections, injuries to your skin, smoking and intense sun exposure can all worsen psoriasis.

Reduce stress,  the relationship between stress and psoriasis is unclear and needs further study. Stress at work? If it’s possible that easing stress in your life might help reduce psoriasis flares and itchiness. Try doing things you enjoy and activities that focus your mind on something other than your stresses. Consider meditation, tai chi, yoga, and spending time with friends and loved ones.

Stay cool, being too hot can make your skin feel itchy. Wear light clothing if you’re outside on hot days. If you have air conditioning, use it on hot days to keep cool. Keep cold packs in your freezer and apply them to itchy spots for a few minutes of relief. You might try storing your moisturizing lotion in the refrigerator to add a cooling effect when you apply it

Strive to maintain a healthy lifestyle,  try practicing other healthy-living habits to help manage psoriasis. These include being active, eating well, limiting or avoiding alcohol consumption, and maintaining a healthy weight.

Don’t be an Evertonian!

Thanks for Reading

Peace

https://www.mayoclinic.org/diseases-conditions/psoriasis/diagnosis-treatment/drc-20355845