Elsevier

The Lancet

Volume 370, Issue 9583, 21–27 July 2007, Pages 272-284
The Lancet

Series
Current and future management of psoriasis

https://doi.org/10.1016/S0140-6736(07)61129-5Get rights and content

Summary

Management of psoriasis begins with identification of the extent of cutaneous disease. However, a holistic, contractual approach to treatment is encouraged, with particular reference to psychosocial disability and quality-of-life issues. The presence of psoriasis on palms, soles, body folds, genitals, face, or nails, and concomitant joint disease, are also important when considering treatment options. An evidence-based approach is essential in delineating differences between the many available treatments. However, archaic approaches, especially combinational ones, are routinely used by some clinicians, with inadequate prospective or comparative evidence. Treatments currently available are: topical agents used predominantly for mild disease and for recalcitrant lesions in more severe disease; phototherapy for moderate disease; and systemic agents including photochemotherapy, oral agents, and newer injectable biological agents, which have revolutionised the management of severe psoriasis. Other innovative treatments are undergoing clinical studies, with the aim of maintaining safe, long-term control of the condition.

Section snippets

General principles

As with any chronic disease, education and a sympathetic approach are important in the initial encounter between patient and doctor. Patients must understand the genetic, environmental, and real-life implications of psoriasis. Exacerbating factors such as stress, excessive alcohol and tobacco consumption, and use of some drugs (including β-blocking agents, lithium carbonate, antimalarials, and interferons) should be avoided, and patients should be assessed for acute infections, particularly

Topical therapy

Topical monotherapy remains the mainstay of treatment for most patients with psoriasis, especially those with limited disease (figure 1). Although effective for individual plaques, it is time consuming, and compliance is a substantial issue. Thus, it is important to individualise and simplify topical therapy and understand the uses of different bases: creams, lotions, foams, sprays, ointments, and gels.

Broadband and narrowband UVB

Natural sunlight has been used for centuries in the treatment of psoriasis. The Dead Sea, because of its unique location below sea level and spectrum of UVR, is an attractive destination for patients, but unfortunately does not result in long remissions of psoriasis. Although the most effective wavelength of UVR for psoriasis was first determined to be in the 311–313 nm (narrowband UVB) range more than 30 years ago,57 only recently have phototherapy units containing these specially designed

Systemic treatments

Traditional systemic agents have been available for psoriasis since methotrexate was first approved by the US Food and Drug Administration in 1971 and remain the mainstay of treatment for patients with moderate to severe disease (figure 3) and those unresponsive to topical agents or phototherapy. Additionally, patients may be suited to systemic treatment if they have physical restrictions (eg, hand or foot psoriasis, associated psoriatic arthritis) or significant quality of life issues. All

Biological agents

An appreciation of the immune pathways critical to the pathogenesis of psoriasis has led to the development of new agents that target these specific steps. Biological agents are recombinant molecules that are designed on the basis of genetic sequences from various organisms and that are often similar or identical to proteins produced by human beings. They include fusion proteins, recombinant proteins (eg, cytokines, selective receptors), and monoclonal antibodies, and are common treatments for

Future treatments

Although biological treatments have been a great advance in the management of psoriasis, their exact place in the hierarchy of systemic therapies will not be known until controlled trials have compared them against each other and with traditional approaches.

Research over the next decade will reveal new, specifically targeted biological therapies for the management of inflammatory immune-mediated diseases, including psoriasis. Anti-interleukin 12/23 agents have shown great promise in phase II

Search strategy and selection criteria

Publications were identified by searching Medline, Ovid, and the Cochrane Library databases with the terms “psoriasis”, “therapy”, “corticosteroids”, “vitamin D3”, “calcitriol”, “tacalcitol”, “calcipotriol”, “calcineurin inhibitors”, “tacrolimus”, “pimecrolimus”, “tazarotene”, “dithranol”, “coal tar”, “ultraviolet”, “phototherapy”, “nb-uvb”, “bb-uvb”, “uva”, “puva”, “psoralen”, “methotrexate”, “retinoid”, “acitretin”, “etretinate”, “ciclosporine”, “fumarates”, “hydroxycarbamide”, “hydroxyurea”,

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