Psoriasis: Practice Essentials, Background, Pathophysiology

Find synonyms Find exact match. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards f Psoriasis evidence. Conflict of interest policy. 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, f Psoriasis are psoriatic arthritis and the management of psoriasis in pregnant women and special populations. See "Epidemiology, clinical manifestations, and diagnosis of psoriasis" and "Treatment of psoriatic arthritis" and "Pathogenesis of f Psoriasis arthritis" and "Clinical manifestations and diagnosis of psoriatic arthritis" and "Management of psoriasis in pregnancy" and "Treatment selection for f Psoriasis to severe plaque psoriasis in special populations".

Therefore, management of psoriasis involves addressing both psychosocial and physical aspects of the disease. Numerous topical and systemic therapies are available f Psoriasis 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 convenienceefficacy, and evaluation of individual patient response [ 1 ]. Although medication safety plays an important role in treatment selection, f Psoriasis must be f Psoriasis by the risk of undertreatment of psoriasis, leading to inadequate clinical f Psoriasis and patient dissatisfaction [ 2,3 ].

The clinician needs to be empathetic and spend adequate time with the patient. It may be helpful for the clinician f Psoriasis 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 f Psoriasis 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. Educating the patient about psoriasis is important and referral to an organization such as the National Psoriasis Foundation www.

Patients with limited skin disease may f Psoriasis have significant psychosocial disability [ 6 ]. However, even patients on systemic therapy will likely continue to need some topical agents.

Topical therapy may provide symptomatic relief, minimize required doses of systemic medications, and may f Psoriasis 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, f Psoriasis 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 f Psoriasis, foot, or face can be debilitating functionally or socially and may deserve a more aggressive treatment approach.

The treatment of article source arthritis is discussed separately. See "Treatment of psoriatic arthritis". Moderate-to-severe psoriasis is typically defined as involvement of more than 5 to 10 percent of the body surface area the entire palmar surface, including fingers, of one hand is approximately 1 percent of the body surface area [ 7 ] f Psoriasis involvement of the face, palm or sole, or disease that is otherwise disabling.

Patients with more than 5 to 10 percent body surface area affected are generally candidates for phototherapy or systemic therapy, since application of topical agents to a large area is not usually practical or acceptable for most patients. Attempts to treat f Psoriasis disease with topical agents are often met with failure, can add cost, f Psoriasis lead to frustration in the patient-clinician relationship. There is ample evidence of efficacy of the newer systemic therapies "biologics" ; however, cost is a major consideration with these agents.

Established therapies such as methotrexate and phototherapy continue to play a role in the management of moderate to severe plaque psoriasis. The management of patients with extensive or recalcitrant disease is a challenge even for experienced dermatologists.

However, the availability of biologic medications has reduced the challenge considerably. The concept that many f Psoriasis 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 and [ 2 ].

Among the survey respondents with psoriasis, 52 percent expressed dissatisfaction with their treatment. Many patients received no treatment, including 37 to 49 percent of respondents with mild psoriasis, 24 to 36 percent of respondents with moderate psoriasis, and 9 to 30 percent of respondents with severe psoriasis.

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.

Management" and "Treatment of psoriatic arthritis". Alternatives include vitamin D analogs, such as calcipotriene and calcitriolf Psoriasis, 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, calcitrioltazaroteneor 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 f Psoriasis treatment regimen simple and using treatment vehicles f Psoriasis the patient finds acceptable is often beneficial [ 8 ]. Improvement usually occurs within weeks. Patients with severe psoriasis generally require care by a dermatologist.

Topical calcipotriene or calcitriol and the topical calcineurin inhibitors tacrolimus or pimecrolimus are additional first-line treatments [ 9,10 ]. 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.

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 [ 11 ]. 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 [ 12 ].

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 f Psoriasis preparations. F Psoriasis topical therapies f Psoriasis for psoriasis eg, tazarotenecoal tar shampoo, anthralin and intralesional corticosteroid injections also may be beneficial for scalp involvement, though data on efficacy specifically in scalp disease are limited [ 11 ].

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 f Psoriasis who cannot achieve sufficient improvement with topical agents [ 11 ]. Approaches include potent topical corticosteroids and topical bath psoralen plus UVA phototherapy PUVA.

See "Psoralen plus ultraviolet A PUVA photochemotherapy". Data are limited on the use of systemic retinoids for localized pustular psoriasis. 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 f Psoriasis 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 [ 13 ].

Patients with less acute disease can be treated with acitretin or methotrexate as first-line agents. F Psoriasis 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.

Data are limited on the efficacy of biologic agents other than infliximab for the treatment of erythrodermic psoriasis. Etanercept was effective in an open-label study of 10 patients [ 14 ], and case reports have documented successful treatment with adalimumab and ustekinumab [ 15,16 ].

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 [ 13 ].

Long-term maintenance therapy for psoriasis is required. Many agents used f Psoriasis the treatment of adult psoriasis have also been used for children [ 17 ]. However, high quality studies on the efficacy and safety of therapies for psoriasis in children are limited.

Guidelines for the treatment of children based upon the available evidence have been published [ 18 ]. See "Treatment selection for moderate to severe plaque psoriasis in special populations" read more "Management of psoriasis in pregnancy".

F Psoriasis guidelines for the treatment of psoriasis with topical therapies are available [ 19 ]. Keeping psoriatic skin soft and moist minimizes the symptoms of itching and tenderness. Additionally, maintaining proper skin hydration can help prevent f Psoriasis and thus the potential for subsequent Koebnerization development of new psoriatic lesions at sites of trauma.

The most effective are ointments such as petroleum jelly or thick creams, especially when applied immediately after a hydrating bath or shower. The mechanism of action of corticosteroids in psoriasis is not fully understood. Corticosteroids exert antiinflammatory, antiproliferative, and immunosuppressive actions by affecting gene transcription. The inherent potency of a topical corticosteroid is frequently reported using a I to VII scale based on vasoconstrictive assays table 1. Although ointments are sometimes thought to be inherently more effective because of their occlusive properties, this is not uniformly correct.

To minimize adverse effects and maximize compliance, f Psoriasis site of application needs to be considered in choosing f Psoriasis appropriately potent corticosteroid:. The typical regimen consists of twice daily application of topical corticosteroids.

Most patients will show f Psoriasis rapid decrease in inflammation with such therapy, but complete normalization of skin or lasting remission is unpredictable. Topical corticosteroids generally can be continued as long as the patient has thick active lesions. Skin atrophy from topical corticosteroids usually is not a problem unless the medication is continuously applied after the skin has returned to normal thickness.

Once clinical improvement occurs, the frequency of application should be reduced [ 19 ]. For patients in whom lesions recur quickly, topical corticosteroids can be applied intermittently such as on weekends only to maintain improvement. The addition of non-corticosteroid topical treatments can also facilitate the avoidance of long-term daily topical corticosteroids. The risks of cutaneous and systemic side effects associated with chronic topical corticosteroid use are increased with high potency formulations.

Data support limiting the continuous application of Class I topical corticosteroids to two to four weeks; thus, close clinician supervision should be employed if longer treatment durations are required table 1 [ 19 f Psoriasis. Data are less clear regarding treatment durations for less f Psoriasis topical corticosteroids.

Side effects of topical corticosteroids, including f Psoriasis potential for suppression of the hypothalamic axis, are f Psoriasis separately. See "Pharmacologic use of glucocorticoids" and "General f Psoriasis of dermatologic therapy and topical corticosteroid use". The cost of topical corticosteroids varies widely. The price of f Psoriasis 60 gram tube of a potent corticosteroid brand name product can be hundreds of dollars.

There are generic preparations in each potency class that have reduced the cost somewhat, though generic prices in the United States are rising f Psoriasis 21 ]. Different formulations have been developed in an effort to enhance the f Psoriasis of topical corticosteroids.

Betamethasone valerate in a foam had superior efficacy for scalp psoriasis and was preferred by patients when compared with betamethasone valerate lotion [ 22 ]. The foam becomes a liquid on contact with skin and is also well tolerated f Psoriasis patients with trunk and extremity psoriasis [ 23 ]. A clobetasol propionate spray is also available; like foams, sprays are easy to apply to large areas [ 24 ].

The main advantage of these newer preparations is likely greater patient acceptance, which may translate into greater adherence; the main disadvantage is cost. Although topical vitamin D analogs are effective as monotherapy for some patients, a systematic review found that combination therapy with a topical corticosteroid is more effective than either treatment alone [ 25 ]. Untilcalcipotriene was the only topical vitamin D analog available in the United States.

Calcipotriene is obtainable as a cream, solution, ointment, or foam, or as a combination ointment, suspension, or foam with f Psoriasis dipropionate. Topical calcitriol ointment has been prescribed in Europe for f Psoriasis, and is now available in the United States.

When compared with calcipotriene, calcitriol f Psoriasis to induce less irritation in sensitive areas f Psoriasis the skin eg, skin folds [ 26 ]. The precise mechanism is not clear, but a major effect is the hypoproliferative effect f Psoriasis keratinocytes [ 27 ]. An immune modulating effect has been postulated for calcipotriene, but has not been shown to be significant in psoriasis to date [ 28 ].

Only potent topical corticosteroids appeared to have comparable efficacy at eight weeks. Skin irritation is the main adverse event associated with calcipotriene. Combined use of calcipotriene and superpotent f Psoriasis has demonstrated increased clinical response and tolerance in clinical trials compared with either agent used alone [ ]. One regimen employed daily use of both calcipotriene ointment and halobetasol ointment for two weeks, followed by weekend use of f Psoriasis halobetasol ointment and weekday use of calcipotriene [ 30 ].

This regimen produced six-month remission maintenance in 76 percent compared with 40 percent with weekend halobetasol alone. A similar regimen with calcipotriene ointment and clobetasol propionate foam also appears to be effective [ 33 ]. In addition, a randomized trial found that a preparation that combines calcipotriene with betamethasone dipropionate 0. Patients who use topical corticosteroids in combination with calcipotriene must be monitored for adverse effects as with corticosteroid monotherapy.

Thus, topical calcipotriene may be used as an alternative or adjunct to topical corticosteroid therapy. It is applied twice daily when used as monotherapy. No controlled trials guide how best to use topical corticosteroids in conjunction with calcipotriene.

Once daily use of each f Psoriasis be adequate. Acidic products can inactivate topical calcipotriene, and f Psoriasis topical corticosteroids may be acidic. A reasonable approach to combination therapy is to have patients apply topical calcipotriene and topical corticosteroids each once daily at different times of day. Other than skin irritation, side effects of topical calcipotriene are usually minimal; the risk of hypercalcemia is low when the drug is used appropriately [ 35 ].

However, topical calcipotriene is more expensive than many generic potent corticosteroids. In addition, calcitriol inhibits T-cell proliferation and other inflammatory mediators [ 36 click the following article. At the end of the study periods up to eight weeks In a systematic review, calcipotriene and calcitriol were equally effective [ 25 ].

However, on sensitive areas of f Psoriasis skin, calcitriol appears to be less irritating than calcipotriene. Perilesional check this out, perilesional edema, and stinging or burning sensations were significantly lower in the areas treated f Psoriasis calcitriol. A week open-label study of the safety of calcitriol ointment did not f Psoriasis an adverse effect on calcium homeostasis [ 38 ].

Similar to calcipotriene, calcitriol ointment is more expensive than many generic potent topical corticosteroids. The drug is applied twice daily. The precise mechanism of action of tar is not known; it has an apparent antiproliferative f Psoriasis. Tar can be helpful as an adjunct to topical corticosteroids.

Tar products are available without a prescription in the form f Psoriasis shampoos, creams, lotions, ointments, and oils. Newer products include a solution and a foam.

Some patients may prefer the less messy formulations. Tar can also be compounded into creams and ointments. Topical tar preparations, including shampoos, creams, f Psoriasis other preparations, can be used once daily. Patients should be warned that tar products have the potential f Psoriasis stain hair, skin, and clothing. It may help to use them at night and wear inexpensive night clothes eg, old pajamas as they tend to be messy. Patients may also find the odor of tar products unpleasant.

For shampoos, the emphasis should be on making sure the product reaches the scalp. Tar shampoo should be left in place for 5 to 10 minutes before rinsing it out.

Another learn more here found that f Psoriasis daily administration of tazarotene gel, 0. Absorption of tazarotene was minimal over the week course of the study, suggesting that systemic toxicity is unlikely during long-term therapy.

A small uncontrolled study of short contact tazarotene found that a 20 minute application followed by washing appeared to be less irritating than traditional use, and seemed to have similar efficacy [ 43 ]. Irritation limits use of tazarotene by itself; the irritation is reduced by concomitant treatment with a topical corticosteroid [ 44 ].

Facial and intertriginous areas may be well suited f Psoriasis these treatments, which can allow patients to avoid chronic topical corticosteroid f Psoriasis. Topical tacrolimus and pimecrolimus are generally well tolerated when used to treat facial and intertriginous psoriasis [ 49,50 ]. However, corticosteroid therapy may be more effective, at least compared with pimecrolimus.

This was suggested in a four-week randomized trial in 80 patients with intertriginous psoriasis that compared various therapies applied once daily [ 51 ]. Inthe US Food and Drug Administration FDA issued an alert about a possible link between topical tacrolimus and pimecrolimus and cases of lymphoma and skin cancer in children and adults [ 52 ], and in placed a "black box" warning f Psoriasis the prescribing information for these medications [ 53 ].

No definite causal relationship has been established; however, f Psoriasis FDA recommended that these agents only be used as second line agents for atopic dermatitis. Subsequent studies have not, however, found evidence of an increased risk f Psoriasis lymphoma [ f Psoriasis ].

The mechanism of action of anthralin in psoriasis is not well understood, but may involve antiinflammatory effects and normalization of keratinocyte differentiation [ 19 ]. Skin irritation is an expected side effect of anthralin that can limit the use of this therapy.

This side effect and the ability of anthralin to cause permanent red-brown stains on clothing and temporary staining of skin have contributed to a decline in the use of f Psoriasis therapy. In order to minimize irritation, anthralin treatment is usually prescribed as a short-contact regimen that is titrated according to patient tolerance.

For example, treatment may begin with concentrations as low as 0. Then, weekly, serial increases in the concentration of anthralin can be performed eg, 0. Subsequently, the application time is titrated f Psoriasis to 20 to 30 minutes as tolerated. Application to surrounding unaffected skin should be avoided to minimize irritation. For patients with well-defined plaques, petrolatum or zinc oxide f Psoriasis be applied to the surrounding skin as a protectant prior to application.

After the desired contact period has article source, anthralin should be washed off the treated area [ 19 ].

Benefit from anthralin therapy is often evident within the first few weeks of therapy. When administered by patients in the outpatient setting, anthralin is less effective than topical vitamin D or potent topical corticosteroid therapy [ 25,60,61 ]. As an example, patients often notice improvement in skin lesions during the summer months. UV radiation may act via antiproliferative effects slowing keratinization and anti-inflammatory effects inducing apoptosis of f Psoriasis T-cells in psoriatic plaques.

In choosing UV therapy, consideration must be given to the potential for UV radiation to accelerate photodamage and increase the risk of cutaneous malignancy.

Phototherapy and photochemotherapy require the supervision of a dermatologist trained in these treatment modalities. The American Academy of Dermatology has provided guidelines for the treatment of psoriasis with ultraviolet light [ 62 ]. Despite f Psoriasis efficacy and safety, the use of office-based phototherapy has declined in the United States because f Psoriasis administrative issues and the development of new systemic medications [ 63 ].

The mechanism of action of UVB is likely through its immunomodulatory effects [ 64 ]. Patients receive near-erythema-inducing doses of UVB at least three times weekly until remission is achieved, after f Psoriasis a maintenance regimen is usually recommended to prolong the remission. Suberythemogenic doses of narrow band UVB are more effective than broadband UVB in clearing plaque psoriasis [ 65 ].

Apoptosis f Psoriasis T cells is also more common with nm than with broadband UVB. With oral PUVA, patients ingest the photosensitizing drug, 8-methoxypsoralen, followed within two hours by exposure to UVA; this sequence is performed three times weekly in increasing doses until remission, then twice or once weekly as a maintenance dose.

With bath PUVA, the psoralen capsules are dissolved in water, and affected skin hands, feet, or total body is soaked for 15 to 30 minutes prior to UVA exposure. There are few data on the comparative f Psoriasis of oral and bath PUVA for psoriasis.

A small open randomized trial of 74 patients with moderate to severe psoriasis did not find a significant difference in efficacy between the two treatments [ 67 ].

Additional studies are necessary to confirm this finding. Some f Psoriasis take psoralen prior to coming into the office or clinic for PUVA. Increased photosensitivity f Psoriasis typically present starting one hour after an oral dose and resolves after eight hours. Pre and post treatment photoprotection eg, hat, sunscreen, sun protective goggles are critical in preventing serious burn injury to the skin and eyes from being outside.

Pretreatment emollients have long been thought to improve results with UVB. However, while thin oils do not impede UV penetration, emollient creams can actually inhibit the penetration of the UV and should not be applied before treatment [ 68 ]. Gentle removal of plaques by bathing does help prior to UV exposure. Uncertainty remains about the comparative efficacy of UVB phototherapy and PUVA photochemotherapy for plaque psoriasis. Randomized trials comparing the efficacy of narrowband UVB to PUVA have yielded inconsistent findings [ 69 ].

The convenience f Psoriasis not needing to administer a psoralen prior to treatment is a favorable feature of UVB phototherapy. This option may be preferred by patients who are not in close proximity to source office-based phototherapy center, whose schedules do not permit frequent office visits, or for whom the costs of in-office treatment exceed those of a home phototherapy unit.

Insurance coverage f Psoriasis these units varies. For some dermatologists, uncertainty regarding the safety of home f Psoriasis has led to a reluctance to prescribe them. Some have expressed concern for the potential for improper or excessive usage of these devices [ 71 ].

In contrast, a randomized trial of subjects f Psoriasis that narrowband UVB administered via home units was as f Psoriasis and effective as office-based treatments [ 71 ]. Home phototherapy units that are equipped with electronic controls that allow only a prescribed number of treatments are available and may f Psoriasis to mitigate clinician concerns. Commercial tanning beds can improve psoriasis and are occasionally used for patients without access to medical phototherapy [ 72,73 ].

However, data f Psoriasis limited on this mode of treatment, and clinicians and patients should be cognizant that there is significant variability in the UV output of tanning beds [ 74 ]. The laser allows treatment of only involved skin; f Psoriasis, considerably higher doses of UVB can be administered to psoriatic plaques at a given treatment compared with traditional phototherapy.

Uncontrolled trials suggest that f Psoriasis therapy results in faster responses than conventional phototherapy [ 75,76 ]. As an example, one study of excimer laser therapy involved patients with stable mild to moderate plaque psoriasis, of whom 80 completed the entire protocol [ 75 ]. Treatments were scheduled twice weekly. After 10 or fewer treatments, 84 and 50 percent of patients achieved the outcomes of 75 percent or better and 90 percent or better clearing of plaques, respectively.

This number of treatments was far fewer than that typically required of phototherapy 25 or more. Side effects of laser therapy included erythema and blistering; these were generally well tolerated, and no patient discontinued therapy because of adverse effects.

A common sequela of excimer laser therapy is the induction of UV-induced hyperpigmentation tanning in treated areas, which can be cosmetically distressing for some patients. Hyperpigmentation resolves after the discontinuation of treatment. Like nm UVB, Kloster Tee Psoriasis Preis in der Apotheke zu kaufen excimer laser represents a therapeutic advance toward specific wavelength therapies for psoriasis.

While both the excimer laser and narrow band UVB are approved for use in psoriasis, inconsistencies in third party coverage for these treatments limit their utilization. Ongoing monitoring is indicated in patients who have received prolonged courses of PUVA. In general, phototherapy is contraindicated in patients with a history of melanoma or extensive nonmelanoma skin cancer. In an in vitro study, exposure of plasma to UVA led to a 30 to 50 percent decrease in the serum folate level within 60 minutes [ 77 ].

However, folate deficiency secondary to UVA exposure has not been proven to occur in vivo. In a small randomized trial of healthy subjects, no difference in serum folate levels was identified between subjects irradiated with UVA for six sessions and untreated subjects [ 78 ].

In addition, an observational study of 35 psoriasis patients found that narrow band UVB had no effect on serum folate levels after 18 treatment sessions [ 79 ]. Bathing in sea water in combination with sun exposure climatotherapy has also been used as a therapy for psoriasis, as has the use of salt water baths with artificial UV exposure balneophototherapy.

A large, open, randomized trial found that treatment with UVB after a saltwater bath had greater efficacy than UVB after a tap-water bath, and similar efficacy to bath PUVA [ 80 ].

Although the raters of disease severity were intended to be blinded, treatment assignment was f Psoriasis to the raters in nearly 60 percent of cases. In per-protocol analyses, no difference was found between saltwater and tap-water baths, and bath PUVA was superior to UVB after a saltwater bath.

Additional studies are required to demonstrate that combining saltwater baths with phototherapy is f Psoriasis to tap-water baths plus phototherapy or to phototherapy alone. In and f Psoriasis, the American Academy of Dermatology f Psoriasis guidelines for the management of psoriasis with systemic f Psoriasis [ 81,82 ]. Inan update to the European S3-Guidelines on the systemic treatment of psoriasis was published [ 84 ].

Options for systemic f Psoriasis include immunosuppressive or immunomodulatory drugs such as methotrexatecyclosporineapremilast and biologic agents.

Systemic retinoids, f Psoriasis improve psoriasis through effects on epidermal proliferation and differentiation as well as immunomodulation, are also used for the treatment of this condition [ 81 ].

The efficacies of the various systemic treatments for psoriasis were compared in a systematic review of randomized trials. Indirect comparisons of the proportion of patients in placebo-controlled trials who achieved f Psoriasis 75 percent improvement in the Psoriasis Area and Severity Index PASI score f Psoriasis 8 to 16 weeks of treatment showed that the efficacy of infliximab within this time f Psoriasis was superior to etanerceptadalimumabustekinumab 45 mg dosealefacept, cyclosporineand methotrexate [ 85 ].

In addition, head-to-head trials included in the systematic review supported the superiority of infliximab and adalimumab over methotrexate therapy and the superiority of ustekinumab over etanercept therapy. Although knowledge of the relative efficacies of systemic treatments for psoriasis is useful, consideration of factors such as drug side effects, patient preference, drug availability, and treatment cost eg, the high cost of biologic agents compared with conventional therapies also play an important role in treatment selection.

It is also effective for the treatment of psoriatic arthritis and psoriatic nail disease. Initial thoughts on the mechanism of action centered around the antiproliferative effects f Psoriasis methotrexate on DNA synthesis in epidermal cells; subsequent evidence supports the concept f Psoriasis it is the immunosuppressive effects of methotrexate on activated T-cells that controls f Psoriasis [ 87 ].

In one trial, patients with moderate to severe plaque psoriasis were randomized to receive oral methotrexate 7. After 16 weeks, the proportion of patients achieving a 75 percent improvement in the PASI score with methotrexate was more than that with placebo but less than with adalimumab 36, 19, and 80 percent, respectively. A placebo-controlled randomized trial evaluating subcutaneous methotrexate After 16 weeks, 37 of 91 patients 41 percent in the methotrexate group achieved 75 percent improvement in the PASI score compared with 3 of 29 patients 10 percent in the placebo group [ 86 ].

Methotrexate is usually administered in an intermittent low-dose regimen such as once weekly. Similar regimens are in use in patients with rheumatoid arthritis. Administration can be oral, intravenous, intramuscular, or subcutaneous; the usual dose range is between 7.

Unlike cyclosporinewhich is generally used for only limited courses of treatment, methotrexate can be used for long-term therapy. Folic acid1 mg daily, protects against some of the common side effects seen with low-dose methotrexate such as stomatitis [ 89 ].

Folate does not appear to protect against pulmonary toxicity, and it is uncertain whether it protects against hepatic toxicity; monitoring for bone marrow suppression and hepatotoxicity are necessary during f Psoriasis. Concurrent use of other medications that interfere with folic acid metabolism, such as sulfa antibiotics, can increase the toxicity of methotrexate.

See "Major side effects of low-dose methotrexate". For patients with one or more risk factors for hepatotoxicity from methotrexateuse of a different systemic drug should be considered.

In f Psoriasis, the AAD and the National Psoriasis Foundation f Psoriasis this recommendation with monitoring guidelines that are dependent upon the presence or absence of risk factors for hepatotoxicity [ 81,91 ]. Risk factors for hepatotoxicity from methotrexate include [ 91 ]:. Patients without risk factors for hepatotoxicity should have liver chemistries drawn every one to three months. If five out of nine serum AST levels are elevated over the course of 12 months, or if the serum albumin level is decreased in the context of normal nutritional status and well-controlled psoriasis, a liver biopsy should be performed.

Liver biopsy should also be considered after a cumulative Hormone Behandlung von Psoriasis ohne of 3. Once patients have reached this dose, options include proceeding with a liver biopsy, continuing to monitor without a liver biopsy, or discontinuing methotrexate therapy. In patients with risk factors for hepatotoxicity for whom f Psoriasis decision is made to proceed with methotrexateliver biopsies are considered earlier in the course of therapy.

Since a fair number of patients will discontinue therapy within the first two to six months, it is reasonable to perform the biopsy after this time period. For patients who continue methotrexate, liver biopsies should be considered after every 1 to 1. Once patients have reached this dose, options include proceeding with a liver biopsy, discontinuing methotrexate, or consulting with a hepatologist for further evaluation.

The retinoid of choice in psoriasis is acitretin. In a pilot study, 6 of 11 patients with psoriasis and HIV infection achieved good to excellent results with acitretin therapy, with four achieving complete clearing of their skin disease [ 92 ]. The usual dose range of acitretin is 25 mg every other day to 50 mg daily. Acitretin can f Psoriasis used in combination with UVB or PUVA therapy.

F Psoriasis in this way, patients have higher response rates with better tolerance and less UV exposure [ 93,94 ]. Monitoring for hypertriglyceridemia and hepatotoxicity are required with retinoid therapy.

Common side effects include cheilitis and alopecia. Acitretin is teratogenic; it is only indicated in men and in women of non-reproductive potential. Pregnancy is contraindicated for three years after discontinuing the drug [ 95 ].

Improvement is generally observed within four weeks. The use of cyclosporine in psoriasis is based upon multiple studies supporting its status as a highly and rapidly effective treatment [ 81, ].

As an example, a placebo-controlled randomized trial found that after eight weeks of treatment f Psoriasis 3, 5, or 7. All three regimens were superior to placebo, and patients who received the 5 mg dose were least likely to require dose alterations due to side effects or lack of efficacy. A few randomized trials have compared the efficacy of cyclosporine and methotrexateutilizing f Psoriasis treatment regimens and providing different results.

Close monitoring is required since renal toxicity and hypertension are common and often limit the long-term use of cyclosporine in patients with psoriasis. See "Cyclosporine and tacrolimus nephrotoxicity".

An f Psoriasis oral f Psoriasis inhibitor, ISA, was efficacious in randomized trials in f Psoriasis with moderate f Psoriasis severe plaque psoriasis, and may have less nephrotoxicity than cyclosporine [ ].

The available biologics for psoriasis have excellent short-term and long-term efficacy and favorable tolerability. Biologic therapies available for the treatment of f Psoriasis in the United States include etanerceptinfliximabadalimumabustekinumabsecukinumaband ixekizumab.

Network meta-analyses evaluating etanerceptinfliximabadalimumaband ustekinumab support the designation of infliximab as the most effective of these biologic agents for psoriasis [ ]. As an example, in the first network meta-analysis of randomized trials for biologic therapy designed to adjust for inter-trial variability in reference arm responses, infliximab was associated with the highest likelihood for achieving 75 percent f Psoriasis in Psoriasis Area and Severity Index PASI 75 scores [ ].

In addition, ustekinumab 45 or 90 mg dose and adalimumab yielded significantly higher PASI 75 rates f Psoriasis etanercept 25 or 50 mg dose. Of note, the network meta-analysis was based upon PASI 75 rates achieved after 8 to 16 weeks of therapy. Therefore, these results may not be applicable to longer periods of drug use.

A subsequent systematic review and meta-analysis that included the newer biologic agent secukinumab and evaluated randomized trials with treatment durations of at least 24 weeks found evidence to support infliximab, secukinumab, and ustekinumab as the most effective long-term therapies [ ].

In a head-to-head trial, a week course of secukinumab was more effective than ustekinumab. Alefacept, another biologic agent, is no longer marketed. F Psoriasis, a biologic agent marketed in India, is not available in the United States. There is a concern that all tumor necrosis factor TNF -alpha inhibitors have the potential to activate latent infections such as f Psoriasis, and increased rates of infection have been seen in patients with rheumatoid arthritis treated with etanerceptf Psoriasisand adalimumab.

In addition, risk for herpes zoster may be increased in patients receiving biologic therapy in combination with methotrexate [ ]. An analysis of data from adults with psoriasis in a large f Psoriasis of patients eligible to receive or receiving conventional systemic or biologic therapy Psoriasis Longitudinal Assessment and Registry [PSOLAR] found a higher risk of serious infections with adalimumab and f Psoriasis compared with non- methotrexate and nonbiologic therapies [ ].

Serious infection rates among patients treated with infliximab, adalimumab, etanerceptand ustekinumab were 2. Among patients who had never received a biologic therapy or methotrexate and patients who had never received a biologic therapy but had received methotrexate, rates were 1. Data from another study of 12, patients in the PSOLAR registry provides some reassurance regarding the use of biologic therapy for psoriasis [ ].

Compared with treatment with non-biologic agents, biologic therapy did not appear to be a significant predictor of death, major adverse cardiovascular events MACEor malignancy.

Patients were not randomized to the different treatment arms in the PSOLAR registry, and therefore f Psoriasis bias could account for differences or lack of differences between groups. Potential side-effects of TNF-alpha inhibitors are reviewed in greater detail separately. See "Tumor necrosis factor-alpha inhibitors: Bacterial, viral, and fungal infections" and "Tumor necrosis factor-alpha inhibitors and mycobacterial infections" and "Tumor necrosis factor-alpha inhibitors: Risk of malignancy" and "Tumor necrosis factor-alpha inhibitors: An overview of adverse effects".

It is approved by the US Food and Drug Administration FDA for adults with psoriatic f Psoriasis and for patients age four years or f Psoriasis with chronic moderate to severe plaque psoriasis. Standard dosing for etanercept for adults is subcutaneous injection of 50 mg twice weekly for the initial three months of therapy, followed by a 50 mg injection once weekly for maintenance therapy. Standard pediatric dosing is 0. A randomized trial of etanercept in adult patients with active but stable plaque psoriasis involving at least 10 percent of the body surface area found three doses of subcutaneous etanercept 25 mg weekly, 25 mg twice weekly, 50 mg twice weekly significantly superior to placebo [ ].

After 12 weeks, there was at least a 75 percent improvement in a psoriasis area and severity index PASI score in 14, f Psoriasis, 49, and 4 percent, respectively.

After 24 weeks, such an improvement was seen in 25, 44, and 59 percent, respectively no patients received placebo for more than 12 weeks. Etanercept f Psoriasis well tolerated with adverse events and infections occurring at similar rates in all four groups. A week randomized trial found similar benefits with subcutaneous etanercept 50 mg twice weekly, and that, compared with f Psoriasis, patients receiving etanercept had significant improvements in measures of fatigue and depression [ ].

Another randomized trial demonstrated efficacy in children and adolescents with moderate to severe plaque psoriasis [ ]. The long-term safety of etanercept for psoriasis is supported by a week study of etanercept 50 mg twice weekly [ ]. The formation of anti- etanercept antibodies has been reported to occur in 0 to 18 f Psoriasis of patients treated with the drug for psoriasis [ ]. F Psoriasis, in contrast to antibodies against infliximab and adalimumab in patients treated for psoriasis with those agents, the formation of anti-etanercept antibodies does not appear to reduce treatment efficacy [ ].

In addition, the findings of a systematic review suggest that the onset of action of infliximab is faster than other commercially available biologic agents [ ]. Infliximab was efficacious for psoriasis in a multicenter randomized trial in patients with severe plaque psoriasis. F Psoriasis duration of response appeared to be longer with the higher dose. More patients treated with infliximab had serious adverse events 12 versus 0including four cases that the authors felt were reasonably related to treatment: At week 16, patients who did not achieve at least 50 percent improvement were able to switch to the alternative therapy.

In addition, patients who f Psoriasis transitioned from methotrexate to infliximab fared better than those who switched to methotrexate from infliximab; 73 versus Wir behandeln der Nägel percent achieved f Psoriasis percent improvement in the PASI score. Maintenance therapy with infliximab also appears to be effective [ , ]. Infliximab was generally well tolerated. In addition to experiencing better maintenance f Psoriasis response, there are some data that suggest that patients who receive continuous maintenance therapy with f Psoriasis may be less likely to experience serious infusion-related reactions than patients who receive intermittent maintenance therapy.

In trials comparing the two modes of maintenance therapy, slightly higher rates of infusion-related reactions have been observed among recipients of intermittent maintenance therapy []. The reason for this observation was unclear. Whether f Psoriasis regimens of intermittent maintenance therapy would be less likely to yield infusion reactions remains to be seen.

Studies in psoriasis, inflammatory bowel disease, and rheumatoid arthritis have suggested that the production of antibodies to infliximab may contribute to the loss of response to infliximab in some patients with these diseases [].

Anti-infliximab antibodies have been reported to occur in 5 to 44 percent of patients who f Psoriasis infliximab for psoriasis []. In Aprilthe FDA approved infliximab f Psoriasis, a biosimilar to infliximab for the treatment of adults with chronic severe plaque psoriasis []. Biosimilar products are approved f Psoriasis upon demonstration of high similarity to an existing biologic drug and absent meaningful differences in safety and efficacy.

Adalimumab is approved by FDA for treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for f Psoriasis therapy or phototherapy.

Standard dosing for adalimumab for adults is an initial subcutaneous injection of 80 mg of adalimumab followed by 40 mg given every other week, beginning one week after the initial dose.

Examples of studies supporting the efficacy of adalimumab include:. After 12 weeks, more patients treated with adalimumab every other week or weekly achieved at least a 75 percent improvement in the PASI score 53 and 80 percent, respectivelyversus 4 percent with placebo.

In an open label extension of the study, improvements were sustained for 60 weeks. After f Psoriasis weeks, disease was cleared or almost cleared in 15 out of 49 patients in the adalimumab group 31 percent compared with 1 out of 23 patients in the placebo group 4 percent. Adalimumab may be an effective alternative for patients who fail to respond to etanercept [ ].

Treatment success rates approached 50 percent Behandlung von Psoriasis Kohl adalimumab 40 mg weekly or every other week was given for an additional f Psoriasis weeks.

Formation of antibodies against adalimumab is reported to occur in 6 to 50 percent of patients treated with adalimumab for psoriasis and may reduce the response to therapy [ , f Psoriasis. Further study is necessary to determine whether f Psoriasis serum levels of adalimumab during treatment will be useful for improving responses to therapy [ f Psoriasis. In Septemberthe F Psoriasis approved adalimumab -atto, a biosimilar to adalimumab, for the treatment of adults with moderate to severe chronic plaque f Psoriasis [ ].

In a randomized trial that compared adalimumab-atto with adalimumab in adults with moderate to severe plaque psoriasis, the two drugs demonstrated similar efficacy and safety after 16 weeks of treatment [ ]. Ustekinumab is indicated f Psoriasis the treatment of adult patients with moderate to severe psoriasis who are candidates for phototherapy or systemic therapy. Dosing of ustekinumab is weight-based. A 90 mg dose given in the same regimen is recommended for adults who weigh more than kg.

Phase III trials have confirmed the efficacy of ustekinumab [ ]. Examples of phase III trial data on ustekinumab therapy include:. Ustekinumab f Psoriasis administered monthly by subcutaneous injection for the first two doses and then every 12 weeks. Responders who were kept on therapy generally maintained improvements in psoriasis f Psoriasis to at least 76 weeks. Serious adverse events were seen at similar rates in the ustekinumab and placebo arms.

Patients who achieved a partial response at week 28 were randomly assigned to continue every 12 week dosing or escalate to every 8 week dosing. More frequent dosing did not enhance response rates at one year in patients receiving 45 mg, but did enhance 75 percent improvement rates in those receiving 90 f Psoriasis 69 versus 33 percent with continued 12 week dosing.

Serious adverse events were again seen at similar rates f Psoriasis the ustekinumab and placebo arms. Trial data on the use of ustekinumab in adolescents with psoriasis are limited. A randomized trial of adolescents ages 12 to 17 years with moderate to severe psoriasis CADMUS found ustekinumab effective in this population [ ].

The response to ustekinumab 0. The efficacy of ustekinumab appears to persist over time. Follow-up data from one of the phase III randomized trials above [ ] demonstrated maintenance of a high level of drug efficacy over the course of three years [ ].

In addition, treatment appears to be well tolerated []. A randomized trial reported superior efficacy of ustekinumab over etanercept for the treatment of psoriasis [ ]. In this trial, patients with moderate to severe psoriasis received 90 mg of ustekinumab at weeks 0 f Psoriasis 4, 45 mg of ustekinumab at weeks 0 and 4, or 50 mg of etanercept twice weekly.

After 12 weeks, 75 percent improvement in the PASI score was observed in Http:// addition, some patients who did not respond to etanercept benefited from treatment with ustekinumab.

Twelve weeks after crossover to 90 mg of ustekinumab administered at weeks 16 and 20 The incidence of serious adverse effects was similar between treatment groups. Data are limited on the best methods for transitioning patients from other therapies to ustekinumab. In a randomized trial TRANSIT trial performed in patients with moderate to severe plaque psoriasis who had insufficient responses to methotrexatemeasures of the efficacy and safety of ustekinumab after 12 weeks were similar among patients who immediately discontinued methotrexate at the start of ustekinumab therapy and patients who gradually withdrew methotrexate during the first four weeks after starting ustekinumab [ ].

Standard doses of ustekinumab f Psoriasis given; patients weighing kg or less and patients weighing more than kg were assigned to 45 and 90 mg doses, respectively. The findings of this study suggest that tapering of methotrexate during the transition to ustekinumab treatment may not be necessary. While there are not extensive data on the use of ustekinumab with methotrexate in patients with psoriasis, ustekinumab is FDA approved as a treatment with or without concomitant methotrexate in patients f Psoriasis psoriatic arthritis.

Because of its immunomodulatory mechanism of action, there is concern that ustekinumab may increase the risk for infections and f Psoriasis. However, five-year safety data showed no dose-related or cumulative sign of increased risk of severe infection or malignancy [ ].

Uncommon drug-related adverse effects, such as reversible posterior leukoencephalopathy syndrome and a lymphomatoid drug eruption have occurred in two separate patients []. See "Reversible posterior leukoencephalopathy syndrome". Although randomized trials have demonstrated efficacy of ustekinumab for psoriatic arthritis, concern has been raised about whether psoriatic arthritis may worsen in certain patients during ustekinumab therapy.

A case series documents four patients with psoriasis in whom psoriatic arthritis flared during ustekinumab therapy [ ]. The meta-analysis found that more major adverse cardiovascular events were reported in patients who received active treatment with ustekinumab or briakinumab than in those who received placebo 10 out of patients versus 0 out of patients.

Although the difference in events was not statistically significant, the trial lengths were short 12 to 20 weeksand the meta-analysis may have been underpowered to detect a significant difference. A review of pooled data from phase II and phase III trials with up to five years follow-up did not reveal an increased risk for f Psoriasis adverse cardiovascular events [ ].

In addition, analysis of data from a large observational study f Psoriasis patients receiving or eligible to receive systemic therapy for psoriasis PSOLAR did not find an association between ustekinumab therapy and major adverse cardiovascular events [ ]. Anti- ustekinumab antibodies have been reported to occur in 4 to 6 percent of patients treated with ustekinumab for psoriasis; however, an effect of anti-ustekinumab antibody formation on treatment efficacy remains to be confirmed [ ].

Standard dosing for plaque psoriasis is mg given subcutaneously once weekly at weeks 0, 1, 2, 3, and 4 followed by mg every four weeks. Doses of mg f Psoriasis sufficient for some patients. Secukinumab is also effective for psoriatic arthritis.

Two week phase III placebo-controlled trials ERASURE trial and FIXTURE f Psoriasis support the efficacy of secukinumab for moderate to severe plaque psoriasis [ ].

In both trials, secukinumab was given as a mg or f Psoriasis dose once weekly for five weeks, then once every four weeks. After 12 weeks, a 75 percent reduction in PASI score was detected in 77 percent of patients in the mg secukinumab group, 67 percent of patients in the mg secukinumab group, 44 percent of f Psoriasis in the etanercept group, and 5 percent of patients in the placebo group.

Secukinumab f Psoriasis demonstrated greater efficacy for moderate to severe plaque psoriasis than ustekinumab with a similar degree of safety. In a prospective trial CLEAR trialadults with moderate to severe plaque psoriasis were randomly assigned to secukinumab mg given at baseline, week f Psoriasis, week 2, and week 3, then every 4 weeks and ustekinumab 45 mg or 90 mg given at baseline, week f Psoriasis, and then every 12 weeks [ ].

After 16 weeks, 90 percent improvement in PASI score occurred in 79 percent of patients in the secukinumab group compared with 58 percent of patients in the ustekinumab group. The rates behandelt See, Psoriasis für wo adverse effects were similar in the two groups. An analysis of additional data from the CLEAR trial revealed that with continued treatment, the greater f Psoriasis of secukinumab persists for at least 52 weeks [ ].

At week 52, 76 percent f Psoriasis patients in the secukinumab group achieved at least 90 percent improvement in the PASI score compared with 61 percent in the ustekinumab group. Safety was comparable between the two groups. Phase III trials support the efficacy of ixekizumab [ ].

Standard dosing for ixekizumab is mg at week 0, followed by 80 mg at weeks 2, 4, f Psoriasis, 8, 10, and Subsequently, 80 mg are given every four weeks.

At week 12, more patients treated with ixekizumab every two weeks or ixekizumab every four weeks achieved PASI 75 than patients treated with etanercept or placebo. In UNCOVER-2, PASI 75 rates were 90, 78, 42, and 2 percent, respectively.

PASI 75 rates in UNCOVER-3 were 87, 84, 53, and 7 percent, respectively. The week induction periods in the UNCOVER trials were followed by week extension periods.

In UNCOVER-1 and UNCOVER-2, patients who responded to f Psoriasis at week 12 clear or minimal psoriasis on static Physician Global Assessment were randomly reassigned to receive 80 mg of ixekizumab every four weeks, 80 mg of ixekizumab every 12 weeks, or placebo. At the week 60 time point, 74, 39, and 7 percent of patients, respectively, still had clear or minimal psoriasis. Patients in UNCOVER-3 continued ixekizumab at a dose of 80 mg every four weeks after the induction period at the discretion of the investigator and patient.

At week f Psoriasis, clear or minimal psoriasis rates among patients initially treated with ixekizumab every f Psoriasis weeks and every four weeks were 75 and 73 percent, respectively. The rates of serious adverse effects f Psoriasis similar in the ixekizumab and placebo groups. Overall, neutropenia, candidal infection, and inflammatory bowel disease occurred in 12, 3, and less than 1 percent of all patients exposed to ixekizumab during weeks 0 to 60, respectively.

Neutropenia was generally transient and did not f Psoriasis in f Psoriasis of ixekizumab. In Februarythe FDA approved brodalumab for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy and have failed to respond or have lost response to other systemic therapies [ ].

In the United States, the drug will only be available through a Risk Evaluation and Mitigation Strategy program due to concerns regarding risk for suicidal ideation and completed suicides in treated patients. Data from phase III randomized trials support the efficacy of brodalumab for moderate to severe plaque psoriasis []. At week 12, more patients receiving mg of brodalumab or mg of brodalumab achieved PASI 75 compared with patients in the placebo group 86, 67, and 8 percent, respectively [AMAGINE-2], and 85, 69, and 6 f Psoriasis, respectively [AMAGINE-3].

In addition, the rate of complete clearance of skin disease PASI at week 12 was higher among patients given mg of brodalumab compared with patients receiving ustekinumab 44 versus 22 percent, respectively [AMAGINE-2], and 37 versus 19 percent, respectively [AMAGINE-3]. A statistically significant benefit of the mg dose of brodalumab over ustekinumab for achieving PASI was evident in AMAGINE-3 at week 12 but not f Psoriasis AMAGINE Mild to moderate Candida infections were more frequent in the brodalumab groups than in the ustekinumab and placebo groups, and neutropenia occurred more frequently in the brodalumab and ustekinumab groups than in the placebo group.

In addition, two suicides occurred in patients f Psoriasis brodalumab in crossover and open-label phases of AMAGINE However, in lateproduction and distribution of alefacept was discontinued by the drug manufacturer [ ].

The discontinuation of production was neither due to new safety concerns nor a mandatory recall. Alefacept was generally considered to be less effective for psoriasis f Psoriasis other biologic therapies.

Itolizumab is not available in the United States. The findings of a phase III trial support the superiority of itolizumab compared with placebo for the treatment of moderate to severe plaque psoriasis [ ]. However, response rates in the phase III trial were lower than those reported in phase III trials of infliximabadalimumaband ustekinumab therapy [ ,, ]. F Psoriasis efficacy of itolizumab has not been directly compared with other biologic agents.

These drugs include hydroxyurea6-thioguanine, and azathioprinewhich have a place in the treatment of psoriasis when other systemic modalities cannot be used, and tacrolimuswhich is similar to cyclosporine and requires larger studies before it can be considered an accepted alternative [ f Psoriasis ]. Daclizumabwhich is used for prevention f Psoriasis renal transplant rejection, and f Psoriasis cancer chemotherapeutic drug paclitaxel f Psoriasis also under investigation for use in severe psoriasis [f Psoriasis. Phosphodiesterase 4 inhibition reduces production of multiple cytokines involved in f Psoriasis pathogenesis of psoriasis.

Apremilast is costly, priced closer to biologics than to methotrexate. Apremilast is indicated for the treatment of moderate to severe plaque psoriasis in patients who are candidates for phototherapy or systemic therapy. The approval was supported by the findings of two week multicenter randomized trials in which a total adults with f Psoriasis to severe psoriasis were randomly assigned to receive 30 mg f Psoriasis apremilast twice daily or placebo [ ].

In the first trial, 33 percent of patients treated with apremilast achieved 75 percent improvement in the Psoriasis Area and Severity Index PASIcompared with only 5 percent of patients in the placebo group.

Results of the second trial were similar; 29 percent of adults f Psoriasis with apremilast achieved PASI, compared with 6 percent of patients in the placebo group. Although apremilast represents an alternative systemic agent for the treatment of psoriasis, reported treatment success rates with apremilast are lower than those frequently reported for cyclosporineanti-TNF biologic agents, and ustekinumab [ 85 ].

The use of a 30 mg twice daily dose f Psoriasis apremilast is further supported by a phase II randomized trial of adults with moderate to severe plaque psoriasis that f Psoriasis lower efficacy with reduced doses. Among patients treated with 30 mg twice daily, 20 mg twice daily, 10 mg twice daily, and placebo, PASI was achieved by 41, 29, 11, and 6 percent of patients, respectively [ ].

Apremilast is associated with a short-term risk of diarrhea, especially when treatment is started, occurring in roughly 15 to 20 percent of patients. Tolerability of apremilast is improved by slowly ramping up the dose when treatment is initiated. The recommended dose titration schedule for adults is as follows:.

In adult patients with severe renal impairment the recommended final dose is 30 mg once daily. At the start of therapy, only the morning dose of the above titration schedule is given.

Examples of other reported side effects of apremilast include nausea, upper respiratory infection, headache, and weight loss. Periodic monitoring of weight is recommended [ ]. Advising patients, their caregivers, and families to be alert for worsening daisy Schuppenflechte, suicidal thoughts, or other mood changes during treatment also is suggested based upon the possibility of a slight increase f Psoriasis risk for depression [ ].

A systematic review of randomized trials found evidence to support superior efficacy of fumaric acid esters compared with placebo for psoriasis; f Psoriasis, the quality of the evidence was low overall [ ]. In a randomized trial of 60 patients with moderate to severe psoriasis, reductions in disease severity after treatment with fumaric acid esters were similar to those observed with methotrexate therapy [ ]. Additional trials of fumarates are being performed.

Lymphopenia is an occasional side effect of treatment with fumaric acid esters. Intwo cases of progressive multifocal leukoencephalopathy PML were reported in f Psoriasis who continued to receive long-term fumaric acid ester therapy despite the development of severe lymphopenia []. These patients did not have other known causes of immunodeficiency. PML in the setting of fumaric acid therapy for psoriasis has also been reported in a patients without severe lymphocytopenia [].

A systematic review that evaluated data on tonsillectomy for guttate or plaque psoriasis from controlled and observational studies including case reports and case series found that the majority of reported patients experienced improvement in psoriasis after tonsillectomy of patients [ ].

Lengthening of psoriasis remissions and improvement in response to treatments for psoriasis were also documented. However, f Psoriasis were insufficient to recommend the routine use of tonsillectomy for psoriasis because most of the patient data were derived from case reports and case f Psoriasis and publication f Psoriasis may have contributed to the favorable results. Further study is necessary to confirm the effects of tonsillectomy on psoriasis.

Given the limitations of the available data, tonsillectomy should be reserved for select patients with recalcitrant psoriasis that clearly exhibits exacerbations related to episodes of tonsillitis [ ]. Tonsillectomy is not a wie viel ist die von Psoriasis Meer procedure; infection, hemorrhage, laryngospasm, bronchospasm, temporomandibular joint dysfunction, vocal changes, and rarely airway compromise are potential adverse effects [ ].

Relapse f Psoriasis tonsillectomy is also possible. Because of the potential morbidity associated with tonsillectomy, a method to determine which patients are most likely to benefit from the procedure would be of value. These therapies are designed to mediate psoriasis through a variety of mechanisms. Drugs such as briakinumab [ ] have been developed to target this pathway.

Marketing plans for briakinumab have been suspended, and it remains uncertain whether the drug will become available for clinical use. Examples of small molecules that are being studied for the treatment of psoriasis include molecules that block Janus kinases JAK [ ], lipids [ ], and a protein kinase C inhibitor [ ].

In a phase III trial that randomly assigned adults with moderate to severe plaque psoriasis to treatment with tofacitinib 10 mg twice daily, tofacitinib 5 mg twice daily, etanercept 50 mg twice weeklyor placebo, tofacitinib 10 mg twice daily was superior to placebo and non-inferior to etanercept f Psoriasis achieving 75 percent improvement in PASI score [ ].

By week 12, 64, 40, 59, and 6 percent of patients treated with tofacitinib 10 f Psoriasis twice daily, tofacitinib 5 mg twice daily, etanercept, and placebo achieved this endpoint, respectively. Additional phase III trials comparing tofacitinib 10 mg twice daily, tofacitinib 5 mg twice daily, and placebo for chronic plaque f Psoriasis also have demonstrated efficacy f Psoriasis tofacitinib therapy [ ].

The best results are achieved with 10 mg f Psoriasis dosing. The onset of effect of tofacitinib can be fairly rapid, with responses evident by week 4, and there are data to support the efficacy of tofacitinib through two years [ ].

Treatment is generally well tolerated. Tofacitinib may increase risk for infection. Elevations of f Psoriasis and creatine phosphokinase levels also may occur during therapy []. In addition, a phase II randomized trial found that a topical formulation of tofacitinib was more effective for plaque psoriasis than vehicle [ ].

In this study, patients were randomly f Psoriasis to treatment with daily doses of baricitinib 2, 4, 8, or 10 mg, or placebo. At 12 weeks, more patients f Psoriasis the baricitinib 8 and 10 mg groups than those in the placebo group achieved a 75 percent improvement in the F Psoriasis score from baseline f Psoriasis, 54, and 17 percent, respectively. Adverse effects were more common among patients receiving the highest baricitinib doses and included infections, lymphopenia, neutropenia, anemia, and elevation of creatine phosphokinase.

Ponesimod, a selective modulator of S1PR1 also studied for the treatment of multiple sclerosis, induces internalization of S1PR1, thereby f Psoriasis sphingosine 1-phosphate S1P -induced egress of lymphocytes.

In a phase II randomized trial that evaluated ponesimod in patients with moderate to severe chronic plaque psoriasis, patients treated with ponesimod were significantly more likely than patients treated with placebo to achieve a 75 percent reduction in PASI score after 16 weeks [ ].

In a small randomized trial, a novel f Psoriasis of topical cyclosporine using liposomal carriers to improve penetration of the stratum corneum demonstrated efficacy for limited chronic plaque psoriasis [ ]. See "Society guideline links: These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

These articles are written at the 10 th to 12 th grade reading level and are best for patients f Psoriasis want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic.

F Psoriasis encourage you to print or e-mail these topics to your patients. You can also locate patient education articles f Psoriasis a variety of subjects by searching on "patient info" f Psoriasis the keyword f Psoriasis of interest. Psoriasis The Basics ". Psoriasis Beyond the Basics ". The National Psoriasis Foundation is a nonprofit organization that provides useful information to patients with psoriasis and their clinicians.

Membership includes access to a newsletter that provides information on current areas of research and new treatments. Brochures on various forms of psoriasis treatment topical, phototherapy, systemic agents and specific fact sheets on each biologic treatment are available from the Foundation and its website. Treatment modalities are chosen on the basis of disease severity, relevant comorbidities, patient preference including cost and convenienceefficacy, and evaluation of individual patient response.

Alternatives include tar, topical retinoids tazarotenetopical vitamin D, and anthralin. For facial or intertriginous areas, topical tacrolimus or pimecrolimus may f Psoriasis used as alternatives or as corticosteroid sparing agents.

Improvement can be anticipated within one or two months. Combination regimens may be required, including localized phototherapy. Patient adherence may be the largest barrier to treatment f Psoriasis with topical therapies; early follow-up one week after starting treatment may improve compliance. In patients with contraindications to phototherapy or who have failed phototherapy, we suggest treatment with a systemic agent Grade 2B.

Financial considerations or time constraints may also make systemic therapy preferable to phototherapy f Psoriasis some patients. Systemic agents include retinoids, methotrexatecyclosporineapremilastand biologic immune modifying agents such as adalimumabetanerceptinfliximabustekinumabsecukinumabixekizumaband brodalumab. Treatment of psoriatic arthritis f Psoriasis discussed in detail separately.

Improvement should be observed within weeks. Patients with moderate to severe psoriasis source systemic treatment will generally require care by a dermatologist. All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue. It seems to us that you have your JavaScript turned off on your browser.

JavaScript is required in order for our site to behave correctly. Please enable your JavaScript to continue use our site. Search in your own language:. UpToDate allows you to search in the languages below. Please select your preference. Topics will continue to be in English. The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions.

Author Steven R Feldman, MD, PhD. Section Editors F Psoriasis P Dellavalle, MD, PhD, MSPH Kristina Callis Duffin, MD. Deputy Editor Abena O Ofori, MD. Galderma [Psoriasis Clobetasol, calcitriol ]; National Biological Corporation [Psoriasis Phototherapy equipment ] Pfizer [Psoriasis Tofacitnib ]; Novartis [Psoriasis Secukinumab ]; Lilly [Psoriasis Ixekizumab ]; Taro [Psoriasis Desoximetasone ].

Janssen [Psoriasis Ustekinumab, infliximab, golimumab ]; Celgene [Psoriasis Apremilast ]; Novartis [Psoriasis Secukinumab ]; Lilly [Psoriasis Ixekizumab ]. Pfizer Pharmaceuticals [Independent research grant to the University of Colorado Development of patient decision aids ]. Editorial stipends from Journal of Investigative Dermatology and the Journal of the American Academy of Dermatology.

Amgen [Psoriasis Etanercept and brodalumab ]; AbbVie Inc. Abena O Ofori, MD Nothing to disclose. All topics are updated as new evidence f Psoriasis available and our peer review process is complete. Literature review current through: This topic last updated: To minimize adverse effects and maximize compliance, the site of application needs to be considered in choosing the appropriately potent corticosteroid: Facial and intertriginous areas may be well suited to these f Psoriasis, which can allow patients to avoid chronic topical corticosteroid use: Inan update to the European S3-Guidelines on the systemic treatment of psoriasis was published [ 84 ] Options for systemic therapy include immunosuppressive or immunomodulatory drugs such as methotrexatecyclosporineapremilast and biologic agents.

Risk factors for hepatotoxicity from methotrexate include [ 91 ]: Examples of studies supporting the efficacy of adalimumab include: Examples of phase III trial data on ustekinumab therapy include: The f Psoriasis dose titration schedule for adults is as follows:

F Psoriasis

Psoriasis is a long-lasting autoimmune disease which is characterized by patches of abnormal skin. They may vary in severity from small and localized to complete body coverage. There are five main types of psoriasis: It typically presents with red f Psoriasis with white scales on top.

Areas f Psoriasis the body most commonly affected are the back of the forearms, shins, around the navel, and the scalp. F Psoriasis and toenails are affected in most people at some source in time.

This may include f Psoriasis in the nails or changes in nail color. Psoriasis f Psoriasis generally thought to f Psoriasis a genetic disease which is triggered by environmental factors. Symptoms often worsen during f Psoriasis and with certain medications such as beta blockers or NSAIDs. The underlying mechanism involves the immune system reacting to skin cells.

Diagnosis is typically based on the signs and symptoms. There is no cure for psoriasis. However, various treatments can help control the symptoms. These areas are called plaques and are most commonly found on the elbows, knees, scalp, and back. It may more info accompanied by severe itching, swelling, and pain. It is often the result of an exacerbation of unstable plaque psoriasis, particularly following the abrupt withdrawal of systemic glucocorticoids.

They include pustular, inverse, napkin, guttate, oral, and seborrheic-like forms. Pustular psoriasis f Psoriasis as raised bumps filled with noninfectious pus pustules. Inverse f Psoriasis also known as flexural psoriasis appears as smooth, inflamed f Psoriasis of skin. The patches frequently affect skin foldsparticularly around the genitals between the thigh and grointhe armpitsin the skin folds of an overweight abdomen known as panniculusbetween the buttocks in the intergluteal cleft, f Psoriasis under the breasts in the inframammary fold.

Heat, trauma, and infection are thought to play a role in the development of this atypical form of psoriasis. Napkin psoriasis is a subtype of f Psoriasis common in infants characterized by red papules with silver scale in the diaper area that may extend to the torso or limbs.

Guttate psoriasis is characterized by numerous small, scaly, red or pink, droplet-like lesions papules. These f Psoriasis spots of psoriasis appear over large areas of the body, primarily the trunk, but also the limbs and f Psoriasis. Guttate psoriasis is often triggered by a streptococcal infection, typically streptococcal pharyngitis.

Psoriasis in the mouth is very rare, [21] in contrast to lichen planusjust click for source common papulosquamous disorder that commonly involves both the skin and mouth. When psoriasis involves the oral mucosa the lining of the mouthit may be asymptomatic, [21] but it may appear as white or grey-yellow plaques. The microscopic appearance of oral mucosa affected by geographic tongue migratory stomatitis is very similar to the appearance of psoriasis.

Seborrheic-like psoriasis is a common form of psoriasis with clinical aspects of psoriasis and seborrheic dermatitisand may be difficult to distinguish from the latter. This form of psoriasis typically manifests as red plaques with greasy scales in areas of higher sebum production such as the scalpforeheadskin folds next to the noseskin surrounding the mouth, skin on the chest above the sternumand in skin folds.

Psoriatic arthritis is a form of chronic inflammatory arthritis that has a highly variable clinical presentation and frequently occurs in association with skin and nail psoriasis. This can result in a sausage-shaped swelling of the fingers and toes known as dactylitis. Psoriasis can affect the nails and produces a variety of changes in the appearance of finger and toe nails. In addition to the appearance and distribution of the rash, specific medical signs may be used by medical practitioners to assist with diagnosis.

Around one-third of people with psoriasis f Psoriasis a family history of the disease, and researchers have identified genetic loci associated with the condition. These findings suggest both a genetic susceptibility und Melanom Psoriasis an environmental response in developing psoriasis.

Psoriasis has a strong hereditary component, and many genes are associated with it, but it is unclear how those genes work together. Most of the identified genes relate to the immune system, particularly the major histocompatibility complex MHC and T cells.

Genetic studies are valuable due to their ability to identify molecular mechanisms and pathways for further study and potential drug targets. Classic genome-wide linkage analysis has identified nine loci on different chromosomes associated f Psoriasis psoriasis.

They are called psoriasis susceptibility 1 through 9 PSORS1 through PSORS9. Within those loci are genes on pathways that lead to inflammation. Certain variations mutations of those genes are commonly found in psoriasis. Check this out of these genes express inflammatory signal proteins, which affect cells in the immune system that are also involved in psoriasis.

Some of these genes are also involved in other autoimmune diseases. PSORS1 is located on chromosome 6 in the major histocompatibility complex MHCwhich controls important immune functions. Three genes in the PSORS1 locus have a strong association with psoriasis vulgaris: HLA-C variant HLA-Cw6[31] which encodes a MHC class I protein; CCHCR1variant WWC, f Psoriasis encodes a coiled protein that is overexpressed in psoriatic epidermis; and CDSNvariant allele 5, which encodes corneodesmosina protein which f Psoriasis expressed in the granular and cornified layers of the epidermis and upregulated in psoriasis.

Two major immune system genes under investigation are interleukin subunit f Psoriasis IL12B on chromosome 5q f Psoriasis, which expresses interleukinB; and IL23R on chromosome 1p, which expresses the interleukin receptor, and is involved in T cell differentiation. Interleukin f Psoriasis and IL12B have both been strongly linked with psoriasis.

A rare mutation in the gene encoding for the CARD14 protein plus an environmental trigger was enough to cause plaque psoriasis the most common form of psoriasis. Conditions reported as worsening the disease include f Psoriasis infections, stress, and changes in season and climate.

The rate of psoriasis in HIV-positive individuals is comparable to that of HIV-negative f Psoriasis, however, psoriasis tends to be more severe in people infected with HIV. Psoriasis has been described as f Psoriasis after strep throatand may be worsened by skin or gut colonization with Staphylococcus aureusF Psoriasisand F Psoriasis albicans.

Drug-induced psoriasis may occur with beta blockers[10] lithium[10] antimalarial medications[10] non-steroidal anti-inflammatory drugs[10] terbinafine f Psoriasis, calcium f Psoriasis blockerscaptoprilglyburidegranulocyte f Psoriasis factor[10] interleukinsinterferons[10] lipid-lowering drugs[15]: Psoriasis is characterized by an abnormally excessive and rapid growth of the epidermal layer of the skin.

Dendritic cells bridge the innate immune system and adaptive immune system. They are increased in psoriatic lesions [44] and induce the proliferation of T cells and type 1 helper T cells Th1. A diagnosis of psoriasis is usually based on the appearance of the skin. Skin characteristics typical for psoriasis are scaly, erythematous plaques, papules, or patches of skin that may be painful and itch.

Medicine Was ist neu bei der Behandlung von Psoriasis Cardiorenal the clinical diagnosis is uncertain, a skin biopsy or scraping may be performed to rule out other disorders and to confirm the diagnosis. Skin from a biopsy will show clubbed epidermal projections that interdigitate with dermis on microscopy. Epidermal thickening is another characteristic histologic finding of psoriasis lesions.

Unlike their mature counterparts, these superficial cells keep their f Psoriasis. Psoriasis is classified as a papulosquamous disorder and is most commonly subdivided into different categories based on histological characteristics. Each form has a dedicated ICD code. Another classification scheme considers genetic and demographic factors.

Type 1 has a positive family history, starts before the age of 40, and is associated with f Psoriasis human leukocyte antigenHLA-Cw6. Conversely, type 2 does not show a family history, presents after age 40, and is not associated with HLA-Cw6. The classification of psoriasis as an autoimmune disease has sparked considerable debate. Researchers have proposed differing descriptions of psoriasis and psoriatic arthritis; some authors have classified them as autoimmune diseases [17] [31] [57] while others have classified them as distinct from autoimmune diseases and referred to them as immune-mediated inflammatory diseases.

There is no consensus about how to classify the severity of psoriasis. The DLQI score ranges from 0 minimal impairment to 30 maximal impairment and is calculated with each answer being assigned 0—3 points with higher scores indicating greater social or occupational impairment. The psoriasis area severity index PASI is the most widely used measurement tool for psoriasis.

PASI assesses the severity of lesions and the area affected and combines f Psoriasis two factors into a single score from 0 no disease to 72 maximal disease. While no cure is available for psoriasis, [43] many treatment options exist. Topical agents are typically used for mild disease, f Psoriasis for moderate disease, and systemic f Psoriasis for severe disease.

Topical corticosteroid preparations are the most effective f Psoriasis when used continuously for 8 read more retinoids and coal tar were found to be of limited benefit and may be no better than placebo.

Vitamin D analogues such as paricalcitol were found to be significantly superior to placebo. Combination therapy with vitamin F Psoriasis and a corticosteroid was superior to either treatment alone and vitamin D was found to be superior f Psoriasis coal tar for chronic plaque psoriasis.

Moisturizers and emollients such as mineral Forum Shampoo Psoriasispetroleum jellycalcipotrioland decubal an oil-in-water emollient were found to increase the clearance of psoriatic plaques.

Emollients have been shown to be even more f Psoriasis at clearing psoriatic plaques when combined with phototherapy. The emollient salicylic acid is structurally similar to para-aminobenzoic acid PABAcommonly found in sunscreen, and is known to interfere with phototherapy in psoriasis.

Coconut oilwhen used as f Psoriasis emollient in psoriasis, has been found to decrease plaque clearance with phototherapy. Ointment and creams containing coal tardithranolcorticosteroids i. The use of the f Psoriasis tip unit may be Psoriasis Eier in guiding how much topical treatment to use. Vitamin D analogues may be useful with steroids; however, alone have a higher rate of side effects.

Another topical therapy used to treat psoriasis f Psoriasis a form of balneotherapywhich involves daily baths in the Dead Sea. This f Psoriasis usually done for four weeks with the benefit attributed to sun exposure and specifically UVB light. This is cost-effective and it has been propagated as an effective way to treat psoriasis without medication.

Phototherapy in the form of sunlight has long been used f Psoriasis psoriasis. F Psoriasis UVB lamps should have a timer that f Psoriasis turn off the lamp when the time ends.

One f Psoriasis the problems with clinical phototherapy is the difficulty many patients have gaining access to a facility. Indoor f Psoriasis resources are almost ubiquitous today and could be considered as a means f Psoriasis patients to get UV exposure when dermatologist provided phototherapy is not available.

However, a concern with the use of commercial tanning is that tanning beds that primarily emit UVA might not effectively treat please click for source. One study found that plaque psoriasis is f Psoriasis to erythemogenic doses of either UVA f Psoriasis UVB, as exposure to either can cause dissipation of psoriatic plaques. It does require more energy to reach erythemogenic f Psoriasis with UVA.

UV light therapies all have risks; tanning beds are no exception, particularly in the link between UV light and the increased f Psoriasis of skin cancer.

There are increased risks of melanoma, squamous cell and basal cell carcinomas; younger psoriasis patients, particularly those under age 35, are at increased risk from melanoma from UV light treatment. The World Health Organization WHO listed tanning beds as carcinogens. A review of studies recommends that people who are susceptible to skin cancers exercise caution when using UV light therapy as a treatment.

A major mechanism of NBUVB is the induction of DNA damage in f Psoriasis form of pyrimidine dimers. This type of phototherapy is useful in the treatment of psoriasis because the formation of these dimers interferes with the cell cycle and stops f Psoriasis. The interruption of the cell cycle induced by NBUVB opposes the characteristic rapid division of skin cells seen in psoriasis.

The most common short-term side effect of this form of phototherapy is redness of the skin; less common side f Psoriasis of NBUVB phototherapy are itching and blistering f Psoriasis the treated skin, irritation of the eyes in the form of conjunctival inflammation or f Psoriasis of the corneaor cold sores due to reactivation of the herpes simplex virus in the skin surrounding the lips.

Eye protection is usually given during phototherapy treatments. Psoralen and ultraviolet A phototherapy PUVA combines the oral or topical administration of psoralen with exposure to ultraviolet A UVA light. The mechanism click action of PUVA is unknown, but probably involves activation of psoralen by UVA light, which inhibits the abnormally rapid production of the cells in psoriatic skin. PUVA is f Psoriasis with nauseaheadachefatigueread article, and itching.

Long-term treatment is associated with squamous cell carcinoma but not with melanoma. Psoriasis resistant to topical treatment and phototherapy may be treated with systemic therapies including medications by mouth or injectable treatments. The majority of f Psoriasis experience a recurrence of psoriasis after systemic treatment is discontinued.

Non-biologic systemic treatments frequently used for psoriasis include methotrexateciclosporinhydroxycarbamidefumarates such as dimethyl fumarateand retinoids. These agents are also regarded as first-line treatments for psoriatic erythroderma. Biologics are manufactured proteins that interrupt the immune process involved in psoriasis. Unlike generalised immunosuppressive drug therapies such as methotrexate, biologics target specific aspects of the immune system contributing to psoriasis.

European guidelines recommend avoiding biologics if a pregnancy is planned; anti-TNF therapies such as infliximab are not recommended f Psoriasis use in chronic carriers of the hepatitis B virus or individuals infected with HIV.

F Psoriasis monoclonal antibodies target cytokines, the molecules that f Psoriasis use to send inflammatory signals to each other. Two drugs that target T cells are efalizumab and alefacept. Efalizumab is a monoclonal antibody that specifically targets the CD11a subunit LFA Individuals with psoriasis may develop neutralizing antibodies against monoclonal antibodies.

Neutralization occurs when an antidrug antibody f Psoriasis a monoclonal antibody such as infliximab from binding antigen in a laboratory test. When infliximab no longer binds tumor necrosis factor alphait no longer decreases inflammation, and psoriasis may worsen. Limited evidence suggests removal of the tonsils may benefit people with chronic plaque psoriasis, guttate psoriasis, and palmoplantar pustulosis.

Uncontrolled studies have suggested that please click for source with psoriasis or psoriatic arthritis may benefit from a diet supplemented with fish oil rich in eicosapentaenoic acid Just click for source f Psoriasis docosahexaenoic acid DHA.

The effect of consumption of caffeine including coffee, black tea, mate, and dark chocolate remains to be determined. There is a higher rate f Psoriasis celiac disease among people with psoriasis. Most people with psoriasis experience nothing more than mild skin lesions that can be treated effectively with topical therapies.

Itching and pain can interfere with basic functions, such as self-care and sleep. Individuals with psoriasis may feel self-conscious about their appearance and have a poor self-image that stems from fear of public rejection and psychosexual concerns. Psoriasis has been associated with low self-esteem and depression is more common among those with the condition. Clinical research has f Psoriasis individuals often experience a diminished quality of life. Several conditions are associated with psoriasis.

These occur more sounds Thai Salbe Psoriasis Bewertungen think in older people. Nearly half of individuals with psoriasis over the age of 65 have at least three comorbidities, and two-thirds have at least two comorbidities.

Psoriasis has been associated with obesity [3] and several other cardiovascular and metabolic disturbances. Cardiovascular disease risk appeared to be correlated with the severity of psoriasis and its duration.

There is no strong evidence to suggest that psoriasis is associated with an increased risk of death from cardiovascular events. Methotrexate may provide a degree of protection for the heart.

The odds of having hypertension are 1. A similar association was noted in people who have psoriatic arthritis—the odds of having hypertension were found to be 2. The link between psoriasis and hypertension is not currently understood. Mechanisms hypothesized to be involved in this relationship include the following: Approximately one third of people with psoriasis report being diagnosed before age Psoriasis affects about 6.

Scholars believe psoriasis to have been included among the various skin conditions f Psoriasis tzaraath translated as leprosy in the Hebrew Biblea condition imposed as a f Psoriasis for slander.

The patient was deemed "impure" see tumah and taharah during their afflicted phase and is ultimately treated by f Psoriasis kohen. They used the term psora to describe itchy skin conditions. Leprosythey said, is distinguished by the regular, circular form of patches, while psoriasis is always irregular.

Willan identified two categories: Psoriasis is thought to have first been described in Ancient Rome by Cornelius Celsus. The was first classified by English physician Thomas Willan. The British dermatologist Thomas Bateman described a possible f Psoriasis between psoriasis and arthritic symptoms in The history of psoriasis is littered with treatments of dubious effectiveness and high toxicity.

The International Federation of Psoriasis Associations IFPA is the global umbrella organization for national f Psoriasis regional psoriasis patient associations and also gathers the leading Hafer Psoriasis in psoriasis and psoriatic arthritis research for scientific conferences every f Psoriasis years. Non-profit organizations the National Psoriasis Foundation in the United F Psoriasis, the Psoriasis Association in the United Kingdom and Psoriasis Australia offer advocacy and education about psoriasis in their respective countries.

Pharmacy costs are the main source of direct expense, with biologic therapy the most prevalent. These costs increase significantly when co-morbid conditions such as heart disease, f Psoriasis, diabetes, lung disease and psychiatric disorders are factored in. The role of insulin resistance in the pathogenesis of f Psoriasis is currently under f Psoriasis. Preliminary research has suggested that antioxidants such as polyphenols may have beneficial effects on the inflammation characteristic of psoriasis.

From Wikipedia, the free encyclopedia. List of human leukocyte antigen alleles associated with cutaneous conditions. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics". J Am Acad Dermatol. Retrieved 22 April National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Retrieved 1 July Identification and Management of Psoriasis and Associated ComorbidiTy IMPACT project team. Drug Des Devel Psoriasis-Symptome zwischen den Beinen. Retrieved 16 March Clinical F Psoriasis 10th ed.

From the Medical Board f Psoriasis the F Psoriasis Psoriasis Foundation". Am J Clin Dermatol. Greenberg, Michael Glick, Psoriasis Sex A.

N Engl J Med. Retrieved 8 October The American Journal of Human Genetics. J Eur Acad Dermatol Venereol. J Int AIDS Soc. A Review of T-cell Subsets and Cytokine Profiles". J Cutan Med Surg. Expert Rev Gastroenterol Hepatol. Clinical dermatology 4th ed. Cytokine Growth Factor F Psoriasis. Br J Community Nurs.

Skin Disease, Immune Response and Cytokines. Clin Rev Allerg Immunol. The International League of Dermatological Societies. Archived from the original on F Psoriasis Am Board Fam Med. Clin Cosmet Investig Dermatol. Br J Clin Dermatol. Arthritis Care Res Hoboken. Cochrane Click at this page Syst Rev. Guidelines of care for the management and treatment of psoriasis with topical therapies".

The Cochrane database of systematic reviews. International Journal of Dermatology. Indian J Dermatol Venereol Leprol. Psoriasis American Academy of Dermatology". A Review of Phase III Trials.

The Point of View of the Nutritionist. Int J Environ Res Public Health Review. Clin Cosmet Investig Dermatol Review. Nat Rev Gastroenterol This web page Review. Health Qual Life Outcomes. Clinical dermatology a color guide to diagnosis and f Psoriasis 5th ed.

Am J Med Sci. Ir F Psoriasis Med Sci Psoriatic and Reactive Arthritis: A Companion to Rheumatology 1st ed. The American Journal of Managed Care. L40 ICD - 9-CM: Diseases of the skin and appendages by morphology. Freckles lentigo melasma nevus melanoma. Aphthous stomatitis oral candidiasis lichen planus leukoplakia f Psoriasis vulgaris mucous membrane pemphigoid cicatricial pemphigoid herpesvirus coxsackievirus syphilis systemic histoplasmosis squamous-cell carcinoma.

Papulosquamous disorders L40—L45— Guttate psoriasis Psoriatic f Psoriasis Psoriatic erythroderma Drug-induced psoriasis Inverse psoriasis Napkin psoriasis Seborrheic-like psoriasis.

Pityriasis lichenoides Pityriasis lichenoides et varioliformis acuta f Psoriasis, Pityriasis lichenoides chronica Lymphomatoid papulosis F Psoriasis plaque parapsoriasis Digitate dermatosisXanthoerythrodermia perstans Large plaque parapsoriasis Retiform parapsoriasis.

Pityriasis rosea Pityriasis rubra pilaris Pityriasis rotunda Pityriasis amiantacea. Hepatitis-associated lichen planus Lichen planus pemphigoides.

Lichen nitidus Lichen striatus Lichen ruber moniliformis Gianotti—Crosti syndrome Erythema dyschromicum perstans Idiopathic eruptive macular pigmentation Keratosis lichenoides chronica Kraurosis vulvae Lichen sclerosus Lichenoid dermatitis Lichenoid reaction of graft-versus-host disease.

Retrieved from " https: Autoimmune diseases Cutaneous conditions Psoriasis. Uses editors parameter CS1 maint: Uses authors parameter Good articles Articles with contributors link Articles with DMOZ links Wikipedia articles with LCCN identifiers RTT.

Navigation menu Personal tools Not logged in Talk Contributions Create account Log in. Views Read Edit View history. Navigation Main page Contents Featured content Current events Random article Donate to Wikipedia Wikipedia f Psoriasis. Interaction Help About Wikipedia Community portal Recent changes Contact page. Tools What links here Related changes Upload file Special pages Permanent link Page information Wikidata item Cite this page.

In other projects Wikimedia Commons. This page was last edited on 27 Juneat Text Ich habe nicht leben will? available under the Creative Commons Attribution-ShareAlike License ; additional terms may apply. By using this site, you agree to the Terms of Use and Privacy F Psoriasis. Privacy policy About Wikipedia Disclaimers Contact Wikipedia Developers Cookie statement Mobile view.

Reditchy, scaly source of skin [3]. Genetic disease triggered by environmental factors [3]. Based on symptoms [4]. Steroid creamsvitamin D3 cream, ultraviolet lightimmune system suppressing medications such as methotrexate [6]. Pustulosis palmaris et plantaris. Wikimedia Commons has media related to Psoriasis. Epidermal wart callus f Psoriasis keratosis acrochordon molluscum contagiosum actinic keratosis squamous-cell carcinoma basal-cell carcinoma Merkel-cell carcinoma nevus sebaceous trichoepithelioma.

Red Blanchable Erythema Generalized drug eruptions viral exanthems toxic erythema systemic lupus erythematosus. Lichen planus f Psoriasis Annular Linear morphology Hypertrophic Atrophic Bullous Ulcerative Actinic Pigmented site Mucosal Nails Peno-ginival Vulvovaginal overlap synromes with lichen sclerosus with lupus erythematosis other:

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