Psoriasis Treatment: The Role of Topical Therapies

Eczema (or psoriasis) is a chronic recurrent disease that affects the skin and, in 5–7% of patients, the joints. The causes of the disease are not entirely clear, and it is considered a serious condition that currently cannot be completely cured. We discuss psoriasis, its causes, and treatment options with dermatologist and venereologist Vilma Polinkevičienė from the Department of Infectious Diseases and Dermatovenereology at the Republican Panevėžys Hospital and the private clinic Tvinksnis (Vilnius).

Please describe the disease. Who is more likely to suffer from it? What is known about the causes of the disease?

Psoriasis is a fairly common chronic inflammatory disease that usually follows a recurrent course and affects the skin and joints. It affects approximately 2–3% of the population and occurs equally in women and men. It is most commonly diagnosed between the ages of 20 and 50, although it can also develop in young children and older adults.

According to the World Health Organization, about 125 million people worldwide have psoriasis, representing approximately 4% of the global population. In Lithuania, the disease affects about 3% of the population.

The exact causes of psoriasis remain unknown. Genetic factors are believed to play an important role, accounting for about 60–70% of cases. Genetic psoriasis has been associated with HLA-B13, HLA-Cw6, and HLA-Bw57 genes. The course of the disease is often aggravated by acute and chronic infections, unhealthy lifestyle habits, stress, persistent emotional tension, contact allergens, other dermatoses (seborrheic dermatitis, xerosis), concomitant diseases (cardiovascular disease, joint disorders, diabetes, depression), and the medications used to treat them.

Is psoriasis a contagious disease?

Psoriasis is not contagious. It is not a malignant disease and does not increase the risk of developing cancer.

How can a family doctor differentiate this disease from other inflammatory skin conditions? Should a family doctor treat it or refer the patient to a specialist?

A family doctor equipped with a dermatoscope can usually distinguish psoriasis from other skin diseases because of its characteristic clinical presentation, the so-called Auspitz triad: a stearin-like scale that is easily removed from the papule; beneath the scale, a thin, shiny pink membrane; and pinpoint bleeding after gentle scraping.

Typical lesion sites include the scalp, earlobes, elbows, knees, and sacral region. Nail involvement may present as "oil spots" and onychodystrophy in more than 50% of patients. Painful, deformed joints may occur in acute forms of the disease. Psoriatic lesions are usually not itchy, although itching may occur when inflammation is severe or the lesions are widespread.

Psoriasis often has a long-lasting and sometimes latent course. Therefore, it is generally advisable for a family doctor to consult a dermatologist to establish an accurate diagnosis. If necessary, the dermatologist performs a skin biopsy and other investigations before selecting the appropriate treatment strategy.

What is the modern treatment for psoriasis?

Treatment depends on disease severity, the extent and location of skin lesions, the patient's age, comorbidities, and treatment costs. Psoriasis is classified as mild, moderate, or severe.

Treatment options include topical therapy, systemic therapy, phototherapy (ultraviolet light), and combination therapy.

For mild disease, topical calcineurin inhibitors, tar preparations, dithranol, salicylic acid ointments, sulfur preparations, emollients, and ultraviolet therapy are prescribed. These measures are often sufficient to control the disease temporarily.

For moderate and severe psoriasis, topical therapy and phototherapy alone are usually insufficient. In these cases, systemic treatment with immunosuppressive drugs (methotrexate), synthetic retinoids, or biological therapy is prescribed.

What mistakes do doctors make? Perhaps the strongest steroid ointments are prescribed too early, leading to skin atrophy and making treatment more difficult later? After all, psoriasis is a lifelong condition.

Because psoriatic skin is less resistant to friction, stretching, trauma, chemicals, and environmental changes, it requires protection. The strongest topical corticosteroids produce the fastest therapeutic response, but their early use should be avoided in mild or moderate psoriasis.

Treatment should always take into account the patient's skin type and concomitant diseases. It is advisable to begin with keratolytic preparations, such as salicylic acid or urea ointments, to remove scales before applying topical corticosteroids.

If the disease onset is not acute, treatment should start with keratolytic preparations, followed, if necessary, by phototherapy and mild topical corticosteroids to reduce the risk of skin atrophy and thinning. Emollients should also be used. Protecting the skin from both excessive dryness and excessive moisture is important, since moist skin folds provide an ideal environment for microorganisms that may subsequently cause inflammation.

What dosage forms are available for patients with psoriasis—ointments, creams, shampoos, gels?

Patients who have had psoriasis for many years usually know which formulation works best for them. Ointments, creams, shampoos, and gels can all be appropriate. However, patients often use either too much or too little medication.

Where does Daivobet® fit in the treatment of psoriasis? Which patients benefit most, and why?

Daivobet® ointment is a medium-potency corticosteroid combination. It is suitable for treating all degrees of psoriasis severity. However, before applying Daivobet®, I recommend using keratolytic preparations to soften and gradually remove the scales, leaving a pink lesion.

Daivobet® ointment is then applied. Each patient responds differently to treatment, but improvement is usually seen within 1–2 weeks. If complete clearing is not achieved, treatment should be continued rather than switching immediately to stronger corticosteroids, which are less favorable for the skin.

Psoriasis symptoms often disappear completely, allowing treatment to be stopped and restarted only when new lesions appear.

The active ingredients in Daivobet® ointment are calcipotriol and betamethasone. The excipients include liquid paraffin, all-rac-alpha-tocopherol, polyoxypropylene-15-stearyl ether, soft white paraffin, and butylhydroxytoluene (E321). Calcipotriol helps normalize skin cell growth, while betamethasone reduces inflammation.

Please discuss a few clinical cases of psoriasis.

In my clinical practice, I devote considerable attention to psoriasis because many patients suffer from this disease, particularly its severe forms. I would like to present two clinical cases.

The first case involved a young man (Figures 1–3) who had suffered from psoriasis since the age of seven. The affected areas migrated over time, but his scalp remained severely affected. He had been treated continuously with Dermovate® ointment (the strongest topical corticosteroid) and Russian ointments without improvement.

After evaluation at the Republican Panevėžys Hospital, treatment with keratolytics for five days, Daivobet® ointment, and emollients was prescribed. The response was excellent. Improvement became evident after four days: the scales disappeared, infiltration decreased, and plaques became thinner.

For maintenance, UVB phototherapy, bathing with emollients, Daivobet® ointment as needed, and Xamiol® gel for the scalp were recommended. At the follow-up visit, further improvement was noted. Plaques remained, but infiltration was barely visible, and the skin was only moderately dry. Increased use of emollients was recommended.

The patient returned one year later with recurrent lesions. However, only minimal infiltration was present, and treatment with topical corticosteroids was no longer necessary.

The second case involved a 48-year-old man (Figures 4–5) who had suffered from psoriasis for more than 40 years. He smoked, experienced considerable stress, and his disease worsened significantly six months earlier following the death of his wife. He also had arterial hypertension, diabetes, and a positive family history of psoriasis.

Before presentation, he had been treated with Dermovate® ointment under occlusion without improvement. Because of inappropriate treatment, the skin on his hands, elbows, and thighs became very thin. He subsequently self-treated with Russian psoriasis ointments.

When his condition deteriorated further, he attended the Republican Panevėžys Hospital. Keratolytic therapy with 5% salicylic acid ointment under occlusion was prescribed. In addition, he underwent 17 sessions of UVB phototherapy combined with moisturizing and lipid-replenishing creams. After the scales were removed and infiltration decreased, Daivobet® ointment was introduced.

At the latest follow-up visit, his condition had improved considerably. Plaques remained, but scaling had almost completely disappeared. The patient continues treatment with keratolytics under occlusion and regular phototherapy.

Thank you for the conversation.

Conversation with Natalija Voronaja

Internistas, 2014; 4(141).