Psoriasis, types and treatments

In my previous article I explained what psoriasis is, its causes and epidemiology, so now I will explain the types and treatments of this disease suffered by more than 125 million people worldwide.

The clinical manifestations of psoriasis are very varied but the most frequent is psoriasis vulgaris or plaque psoriasis characterized by the presence of well-demarcated symmetrical erythematosquamous plaques preferentially located on the extensor zone of the extremities and on the leather. The lesions are usually asymptomatic although patients often report pruritus. Other clinical forms are:

– Guttate psoriasis, which mainly affects children and adolescents, presents with plaques of 2 – 5 mm in diameter that generally appear on the trunk and extremities. They usually appear abruptly after a throat infection.

– Inverse or inverse psoriasis, also known as flexural psoriasis, predominantly affects the inguinal, anal and axillary folds and the lateral aspect of the neck.

– Pustular psoriasis is a rare form of the disease, in which multiple sterile pustules of approximately 2 to 5 mm are seen on an erythematous base and often occurs as a result of irritation from topical, systemic treatments or even after withdrawal of systemic corticosteroids.

– Erythrodermic psoriasis is the least common form and is characterized by extensive redness affecting up to more than 50% of the skin surface.

Joint and nail involvement in psoriasis

Nail involvement in psoriasis varies between 13 and 50% of affected persons and its frequency increases when the disease starts before the age of 30 years, is accompanied by arthritis (where it reaches figures of 70%) or reaches a significant severity.

As for joint involvement in psoriasis, its incidence ranges widely between 1 and 42%, which is undoubtedly influenced by the different criteria used for its definition and by the specialist who treats it. Arthritis is more frequent among patients with nail involvement or erythrodermic and pustular psoriasis. Psoriatic arthritis is a special type of asymmetric seronegative inflammatory inflammatory arthritis that most commonly affects the distal joints and periarticular structures of the fingers and toes as well as the spine.

Treatment for psoriasis

As there is still no curative treatment, the aim of psoriasis treatments is to rid the skin of lesions for as long as possible: this is called “clearing” or “clearing” the psoriasis plaques. There are many treatments for psoriasis, the choice of one or another will depend on the type and severity of psoriasis (measured by extension and severity indexes – PASI, BSA, PGA – and quality of life), location of the lesions, age and sex of the patient and individual characteristics (concomitant pathologies and habitual medication, etc.).

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There are topical treatments (corticosteroids, retinoids, vitamin D derivatives,…), phototherapy (PUVA, UVB, Excimer laser therapy) and systemic treatments (cyclosporine, methotrexate, acitretin, fumaric acid esters, hydroxyurea). These systemic treatments, used in moderate or severe psoriasis, are associated with potentially serious side effects, especially in prolonged treatments. Cyclic, rotational and sequential therapy is used to reduce the risk associated with these systemic drugs.

New drugs for psoriasis

In recent years the emergence of new drugs generated by molecular biology using recombinant DNA technology and directed against cytokines or lymphocyte surface proteins blocking specific steps in the pathogenesis of psoriasis (biological therapy) has brought about a revolution in the treatment of psoriasis. These drugs have demonstrated high efficacy allowing long-term control of the disease in monodrug therapy. There are more than 40 molecules tested for the treatment of psoriasis. The drugs currently approved for the treatment of moderate-severe psoriasis are etanercept, infliximab, adalimumab and golimumab (anti-TNF drugs). Anti-IL12/23 drugs: ustekinumab.

All these biologic treatments appear relatively safe in the short to medium term and have not been shown to be hepatotoxic or nephrotoxic and do not show drug-drug interactions (unlike conventional systemic therapy). However, the risk of long-term immunosuppression and of developing infections or neoplastic processes should be monitored. Special attention to the development of infections such as tuberculosis should be followed especially with the use of anti-TNF.

Undoubtedly, the new biologic therapy is a revolution in the management of psoriatic patients, allowing an effective medium to long term control of the disease. New advances in pharmacogenomics will probably also make it possible in the future to individualize this biologic therapy for each patient by choosing the most effective and safest drug in each case. In the coming years, drugs such as Apremilast, tofacitinib, and anti-IL-17 antibodies will appear to control patients with psoriasis.