What can I do about my Psoriasis

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Although there is no cure for psoriasis there are many things that can be done to help you control the problem and learn to cope with it.

Each person’s psoriasis behaves in a different way and treatment has to be tailored to the individual. Aspects such as social background and psychological profile are relevant. The art of treatment is finding a programme of therapeutic approaches that suits the individual. What suits one person will not necessarily suit the next. Equally, what suits you this year will not necessarily be the best for you next year. So over a number of years it may be necessary to use many of these treatments. Finding a successful therapeutic programme requires a great deal of patience, expertise and co-operation between doctor and patient.
For a treatment to have the best chance of success, you need to follow your doctor’s instructions as exactly as possible. Here are some tips that may help you to do this:

Try to take or use your treatment regularly, at the same time every day, so you get into a routine
Make sure you get your next prescription in plenty of time so you don’t run out
If you are going away, take enough tablets or creams with you to last the whole time
Read and keep the information leaflet that comes with your medication
If in doubt about any part of your treatment, ask your pharmacist, practice nurse or doctor for advice
Keep a record of treatments you have tried in the past and let your doctor know if they caused you any problems
If the cost of your treatment is stopping you from using some or all of the medications advised, talk to your pharmacist about ways of reducing your prescription charges.

What can I do about my general health?
As with most aspects of health, it helps to keep fit and develop a positive attitude. Take regular exercise, and do not abuse your body with drugs, cigarettes and excessive alcohol. It is well established that in some people too much alcohol can aggravate psoriasis. Although there is no relationship between diet and psoriasis, it is sensible to eat a healthy diet and maintain a normal weight.

What about complementary therapies?
In recent years there have been many claims for various complementary or alternative therapies in psoriasisbut very few are supported by good objective evidence of effectiveness. However, there is good evidence that relaxation and stress relieving techniques are helpful. As a rule of thumb, it is sensible to consult your doctor for advice before parting with a sum of money in the hope of buying some ‘miracle cure’.

What treatments are available from my doctor?
Your doctor has a choice of treatments.These can be divided into:

Topical treatments - (ie products like creams and ointments which are applied externally directly on to the skin and act locally)

Systemic treatments - (ie products which are taken internally - by mouth, injection etc - and are distributed throughout the body.

In addition, psoriasis may also respond to treatment with light.

The decision on which one to choose will depend upon many factors including the severity and extent of the disease, what has worked before and your personal preference.

What topical treatments are available?

Emollients - are not going to cure psoriasis, but they are important in the management of psoriasis and offer considerable skin benefits. They clear superficial scale, they lubricate and soften the plaques keeping them more flexible and comfortable so they're less likely to crack, and they help relieve the itch.

The best emollient is the one you prefer, because then you will use it more frequently and gain more benefit. Emollients come in many different formats - creams, ointments, lotion, bath oils and soap substitutes. Dermatologists and dermatology nurses advise using a combination of emollients to form a daily skin care routine. Through regular use of soap substitutes and bath oils, combined with cream/ointment application, each emollient complements the action of the other to keep the skin well hydrated, flexible and comfortable.

Coal tar extracts – these are old but reasonably effective products. Unfortunately coal tar is smelly and stains the skin and clothing, and is understandably not popular with many patients.

Dithranol – another old but effective product. It slows the production of new skin cells and therefore reduces the thickness of the plaque. However, it stains and burns normal skin and needs to be applied with great care. It is usually applied for about 30 minutes and then washed off

Medicines related to Vitamin D – (eg calcipotriol, calcitriol, tacalcitol) a relatively modern treatment which also reduces the rate of cell multiplication. It is easy to apply and does not stain or burn the skin. Consequently it is more popular than dithranol and coal tar. Calcipotriol has been combined with steroids to form a single effective topical treatment.

Topical steroids – (eg hydrocortisone, beclamethasone) these are effective anti-inflammatory drugs which are easy to use and non-irritant. They come in different strengths or potencies, hydrocortisone being the weakest. Their main limitations are that prolonged use can lead to side effects such as thinning of the skin, and stopping them can result in a ‘rebound effect’ causing the psoriasis to get worse.

Medicines related to Vitamin A – (eg tazarotene) another modern treatment which is easy to apply but sometimes may cause dryness and irritation of the skin.

What light treatments are available?

Sunshine improves psoriasis in most individuals. Phototherapy or light therapy is therefore sometimes used to treat psoriasis. There are two main types of light therapy - UVB (Ultraviolet B) and PUVA or photochemotherapy. Both treatments require a measured exposure to a light source and are usually administered in hospital on an outpatient basis.

UVB treatment - light is classified according to wavelength. Visible light has a wavelength of 400-800 nm. UVB light has a wavelength of 290 - 320 nm. It is generally very effective for chronic plaque psoriasis. The main side-effects of treatment include burning, ageing of the skin and the potential for development of skin cancer. Modern UVB lamps emit a narrow wavelength band which allows a higher, more effective, dose of UVB to be delivered to the skin with less burning.

PUVA - combines the use of a photosensitising medication (Psoralen) with long-wave ultraviolet A light (UVA), hence PUVA. UVA light has a wavelength of 320-400nm. On its own, UVA light is usually too weak to be an effective treatment in psoriasis. However, when combined with a photosensitiser it becomes very effective in psoriasis - clearance rates of 85-90% can be achieved and maintained for an average of time of 6 months.

There are two ways of photosensitising the skin prior to PUVA treatment – with tablets or by direct application to the skin. Psoralen tablets are taken by patients 2 hours before exposure to UVA light. Alternatively, topical psoralen may be applied to the skin by mixing it with water and then bathing or soaking in the product (depending on the area of skin to be treated) prior to UVA exposure.

This treatment is sometimes called bath PUVA. The psoralen tablets can produce side-effects of nausea in some patients and PUVA treatment itself can have side-effects including burning, itching, skin ageing and the development of skin cancers.

Due to the skin cancer risk of PUVA treatment there is a life-time maximum amount of treatment allowed per patient. Animal studies have suggested that

PUVA therapy might cause cataracts and although this has never been shown in humans, patients are advised to wear protective spectacles for 12 hours following PUVA treatment.

What systemic treatments are available?

In general these treatments will be considered if your psoriasis has failed to respond to topical treatments, involves a large a body surface area or is a more severe type.

Drugs which block cell division – these include methotrexate, ciclosporin, hydroxurea and azathioprine. They are all effective in many patients but are associated with significant side effects. Your doctor will therefore monitor aspects such as liver and kidney function during treatment with these drugs. Methotrexate is the longest established systemic therapy and is especially useful in severe psoriasis, particularly if there is arthritis and nail involvement

Retinoids – are medicines derived from vitamin A. They are used to treat a number of skin diseases. Their main drawback is that they are known to cause deformities in the unborn child and therefore must be avoided in pregnancy. They are particularly effective in specific types of psoriasis such as pustular psoriasis

Biologicals – are the most recent development in the treatment of psoriasis. They are a group of medicines, usually given by injection, that affect the immune system and block some of the naturally occurring inflammatory chemicals that cause psoriasis. So far, they have been shown to be very effective in some patients with severe disease but not all.