TREATMENTS FOR MODERATE OR SEVERE PSORIASIS
What are the aims of this leaflet?
Patients with psoriasis are usually treated with creams and ointments, which are applied to the skin. These are discussed in a separate leaflet (“Topical treatments for psoriasis”). Sometimes other forms of treatment are needed and this leaflet has been written to help you to understand more about them. It tells you what they are, how they are used, and where you can find out more about them.
What types of treatment are available?
- Phototherapy. Ultraviolet light can be used in several different ways to treat psoriasis.
- Treatments with a variety of tablets.
- Treatments with a variety of injections.
The idea of a tablet or an injection to treat psoriasis is attractive, but most of the tablets and injections used have potentially severe side effects. Most are likely to be started by a dermatologist, and some can be prescribed only from a hospital because:
- They require regular clinical assessments and blood test checks.
- Most have the potential to interfere with other medicines.
- Female patients should not become pregnant while on any of the tablets or injections used to treat psoriasis. Additionally, it is important that male patients taking some of these tablets should not father a child. These pregnancy issues may apply for some time after stopping the tablets.
Treatments with tablets or injections tend to be used:
- When psoriasis has failed to respond to topical treatments, or comes back quickly after clearing with them.
- If the psoriasis is severe.
- If creams and ointments are difficult to apply at certain sites.
Which of these treatments is most suitable for my psoriasis?
The various treatments with light, tablets and injections are discussed individually below, and would also be discussed with you in detail by your dermatologist if you were to start on them. All are effective, but the choice will vary from patient to patient for reasons that are outlined below. All of them carry some potential risks, so they are not used for psoriasis that can be sensibly kept under control with simpler measures. Most patients will need to use some topical therapies as well.
Two types of phototherapy are used, known as UVB and PUVA. UV stands for ultraviolet. UVA and UVB are different parts of normal sunlight. With both of these treatments it is important that you let the staff know about any tablets that you are taking, as some can make the skin unduly sensitive to sunlight, and particularly about any changes in these tablets during your course of treatment. Tablets for joint problems, water tablets (diuretics), and tablets for diabetes are examples of those that can make the skin sensitive to light. It is also important that you remind staff if you have had a gap in treatment, as this may require the dose of light to be reduced (please refer to a separate Patient Information Leaflet on Phototherapy).
Tablets used to treat severe psoriasis
- ACITRETIN: Acitretin (trade name Neotigason) is one of a group of drugs known as retinoids, which are related to Vitamin A. Acitretin is the one usually selected for psoriasis. It is prescribed only in hospitals and is hardly ever used in women of childbearing age (please refer to a separate Patient Information Leaflet on Acitretin).
- CICLOSPORIN: Ciclosporin (previously called cyclosporin) has been used extensively for many years for patients with kidney or other transplants to prevent organ rejection. It is also effective in controlling severe psoriasis. It may take 3-4 weeks before you see benefit from ciclosporin treatment (please refer to a separate Patient Information Leaflet on Ciclosporin).
- METHOTREXAT: Methotrexate has a number of actions that account for its helpful effects in psoriasis. It slows down the rapid division of skin cells that is characteristic of psoriasis, and also reduces inflammation by altering the way the immune system works (please refer to a separate Patient Information Leaflet on Methotrexate).
- Other tablets less commonly used: Other tablets that are less commonly used to treat psoriasis include Hydroxycarbamide, Mycophenolate mofetil and fumaric acid esters (please refer to a separate Patient Information Leaflet on each one of these tablets).
- ROTATIONAL THERAPY: Most patients with severe psoriasis will be helped by at least one of these therapies, but from time to time your doctor may stop or change the treatment to control the disease better and to minimise the risk of side effects.
Injections used to treat severe psoriasis
Special injections collectively named biologics injections are relatively new treatments for psoriasis. They alter the immune system. Some of them may be given through a drip into a vein (infliximab) or as injections into the skin (adalimumab, etanercept and ustekinumab). They are currently used only for patients with very severe psoriasis who are unable to take one of the standard treatments listed above or who have failed to respond to them. Please refer to separate Patient Information Leaflets on Adalimumab, Etanercept, Infliximab and Ustekinumab.
Where can I get more information about psoriasis and its treatment?
NICE guidance on the assessment and management of psoriasis [CG153]: http://www.nice.org.uk/guidance/cg153/informationforpublic
Links to patient support groups:
The Psoriasis Association
Dick Coles House
Northampton, NN4 7BF
Tel: 0845 676 0076
The British Association of Dermatologists has a list of Patient Information Leaflets on its website that deal with psoriasis:
- Psoriasis – an overview
- Topical treatments for psoriasis
- Mycophenolate Mofetil
- Fumaric acid esters
The BAD Biologic Interventions Register (BADBIR)
If you are being treated for moderate to severe psoriasis, you may be asked to take part in the national biologics register. This register is to compare the safety of different treatments for psoriasis and to see how well they work. It was set up to monitor some new treatments for psoriasis called biological treatments. The register will give doctors information on how best to use the treatments available for moderate to severe psoriasis. No information will be passed to the register without your informed consent.
For details of source materials used please contact the Clinical Standards Unit (email@example.com).
This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.
This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel
BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED MARCH 2005
UPDATED SEPTEMBER 2010, NOVEMBER 2013
REVIEW DATE NOVEMBER 2016