Treatments

The first step in treating psoriasis is a proper diagnosis by your doctor. Your doctor will compare the standard symptoms of psoriasis against other possible skin diseases. A skin biopsy is occasionally ordered to confirm or exclude other possible diagnoses. If you have mild psoriasis, non-prescription topical treatments may be sufficient to manage your psoriasis. However, if you have more aggressive psoriasis, your doctor will likely recommend prescription-strength topical treatments, light therapy, biologic treatments, or a combination of these, all of which are explained below. Psoriasis is incurable, and permanent clearance of plaques is rarely achieved, so the treatment goal is to clear as much of your skin as possible and then maintain those gains as long as possible. Your treatment will be designed to meet your particular symptoms, tolerances and lifestyle.

This information about psoriasis treatments is organized under topical and biologic treatments. Click on the name of the treatment to read more about its use and effectiveness:

TOPICAL TREATMENTS

BIOLOGIC TREATMENTS

Corticosteroids
Coal Tar
Anthralin

T Cell Blockers
— Alefacept
— Efalizumab

Calcipotriol
Tazarotene
Calcineurin Inhibitors
Sunlight
Broadband Light Therapy
— Groeckerman Regimen
— Ingram Regimen
Narrowband Light Therapy
Psoralen Light Therapy
Methotrexate
Cyclosporine
Acitretin

TNF Blockers
— Infliximab
— Etanercept
— Adalimumab

Topical Treatments are the first-line treatments for mild psoriasis. Available in prescription and non-prescription formulas and in a wide variety of bases (creams, ointments, lotions, shampoos, gels and sprays) topical treatments deliver different drugs to your skin’s surface. For more aggressive psoriasis, topical treatments are often combined with other treatment approaches, or they are used to maintain gains achieved with other therapies.

Corticosteroids are the most commonly prescribed medications for psoriasis, and are available in low-dose, high-dose and very high-dose preparations. Corticosteroids reduce inflammation, slow down scaling and flaking, and relieve itchiness. Corticosteroids usually work quickly, and the low-dose formulations can be applied almost anywhere on the body. For mild psoriasis limited to a few small plaques, low-dose, non-prescription strength may be all you need. However, if the plaques’ crusts are thick or if they’re widespread, high-dose topical steroids may be prescribed alone or in combination with other treatments.

For example, salicylic acid is often prescribed to help soften thick, scaly crusts that then allow the steroid to penetrate more deeply into the epidermis to the site of inflammation. Sometimes, high-dose corticosteroids are used in rotation with another topical agent, such as applying Calcipotriene twice daily on weekdays and reserving the topical steroid for the weekend. Unfortunately, corticosteroids have their limits. Long-term continuous use (a month or more) of high-dose topical steroids can lead to negative side effects. Also, if you are treating large areas of psoriasis, the drug can be absorbed into the blood stream and cause side effects. Most common are stretch marks and thinning of the skin, which becomes shiny, fragile and easily cut. Other side effects include:

acne or dermatitis around the mouth
rosacea
easy bruising
dilated blood vessels
hair growth
drug tolerance leading to loss of efficacy
vulnerability to infections
“rebound” flare of psoriasis (if the steroid is stopped abruptly).

Coal Tar is one of the oldest, effective treatment methods available for psoriasis, dating back at least a century. It inhibits certain enzymes that contribute to psoriasis and helps slow down the division of skin cells. Coal tar also makes the skin more sensitive to light, which is why it’s often combined with UVB phototherapy (Goeckerman Regimen). Another effective combination is with topical steroids. Today, refined coal tar products are available in a variety of bases: shampoo, bath liquid, skin liquid, cream, ointment and gel. From a patient's perspective, the drawbacks to coal tar are that it can have an unpleasant odour, is messy to apply, stains your clothes and bedding, and can irritate unaffected skin. What’s more, because of the skin’s increased light sensitivity, you must take extra care about sun exposure for the next 24 hours after application, since you can burn more easily.

Anthralin is derived from a natural compound, called Chrysarobin, which is prepared from the araroba tree found in the Amazon rainforests. In India, the same substance is known as Goa powder. Anthralin is most effective on chronic plaque psoriasis, slowing down the high turnover of skin cells and reducing the underlying inflammation. Available by prescription in different concentrations, doctors usually prescribe low-strength anthralin to begin with and gradually increase the potency until the plaques respond. Lower strengths can be left on overnight, whereas higher concentrations (1% or more) should be washed away after 15-20 minutes. Another approach is SCAT (short contact anthralin therapy), during which high-strength anthralin is briefly applied to plaques and then washed off. Over time, the Anthralin is left on for longer times (from 10 minutes to an hour) until there is visible improvement (2 weeks at least). Sometimes, for moderate to severe psoriasis, Anthralin is combined with tar baths and UVB or UVA phototherapy (Ingram regimen). Anthralin is available as a cream, ointment and scalp lotion. Like coal tar, Anthralin can stain hair, skin and fabrics. Newer preparations stain less, if washed off with lukewarm water (hot water sets off the staining action). Anthralin can cause skin irritation and burning. If you have fair skin, it may be best if you avoid it altogether. When applying Anthralin, you might consider wearing disposable gloves to avoid staining and placing gauze dressings around the plaques to protect unaffected skin from irritation. This medication should never be applied to the face, genitals or skin folds.

Calcipotriol (also called Calcipotriene) is a topical form of Vitamin D that slows down skin cell division, helps skin cells to mature and reduces inflammation. Calcipotriol is available as a cream, ointment and scalp solution. Applied to plaques once or twice daily, you’ll usually see improvement within 1-2 months, which is slow compared to topical steroids at 1-2 weeks. Since Calcipotriol isn’t a steroid, you’re spared the risks of the latter’s many side effects. It does, however, occasionally cause irritation after being applied, especially on the face and in skin folds. There have also been some reports of people who after applying Calcipotriol to large areas had developed hypercalcemia (too much calcium in the bloodstream), which can quickly lead to a wide variety of serious disorders. The risk drops to virtually nil, however, if you don’t exceed the maximum adult dose of 100g of Calcipotriol per week. As a result of its good safety profile, Calcipotriol lends itself to combination therapy, notably with topical corticosteroids and systemic therapies such as Methotrexate and Cyclosporine. At first glance, Calcipotriol plus a steroid would seem a natural combination, since the fast-acting steroid would fill the gap while the slower-acting Calcipotriol takes effect. But technical problems in mixing the two molecules reduced efficacy (one requires a pH neutral base and the other, an acidic base). Recently, the problem was solved by a patented process for successfully mixing Calcipotriol with betamethasone diproprionate in a stable cream base, and the resulting combination treatment has proven safer and more effective than either medication alone. One topical treatment that doesn’t combine well with Calcipotriol, however, is salicylic acid, which blocks the action of Calcipotriol.

Tazarotene is a Vitamin A derivative that comes in a cream or gel. It’s a topical retinoid, similar to the oral retinoids that are sometimes prescribed for very severe acne but with a much lower risk of the systemic side effects associated with the oral drugs. Still, if you’re using the cream, you should never apply it to more than 35% of your body’s surface area, and if you’re using the gel, never more than 20%. As a rough measure, the palm of the hand is about 1% of your body’s surface area. As you might expect, you apply only a small amount to each lesion. Tazarotene seems particularly effective at reducing scaling and thick crusts, and less so at reducing inflammation. Tazarotene can cause severe skin irritation at the doses necessary to treat psoriasis. Your skin may become very red while it’s improving. To provide a bit of protection, you can apply zinc oxide ointment (most often used for diaper rash) on the unaffected skin surrounding the plaque. Another solution is to mix a drop of Tazarotene cream or gel with an equal amount of petroleum jelly (Vaseline®) and then gradually increase the Tazarotene in the mix as the areas become less sensitive. Topical steroids are often prescribed in combination with Tazarotene. And because it makes the skin more light sensitive, Tazarotene is often applied before UVB phototherapy. Retinoids, including Tazarotene, cause birth defects and should never be used by women who are pregnant, intending to become pregnant or who are nursing.

Calcineurin Inhibitors were developed to treat eczema (or atopic dermatitis) and currently they are being tested experimentally for psoriasis. Two types of Calcineurin Inhibitors are available: Tacrolimus in a 0.1% and 0.03% ointment, and Pimecrolimus in a 1% cream. These drugs act by blocking a key step in the activation of immune-system T-cells, which are important players in the underlying inflammatory process of psoriasis. So far, study results are mixed. Calcineurin Inhibitors don’t appear to be effective on thick, scaly plaques, but they might have an application as alternatives for topical steroids at sites where the skin is prone to thinning such as the face, armpits and groin.

Sunlight, which has long been used to treat psoriasis, consists of three kinds of radiation. At one end of the light spectrum is invisible ultraviolet (UV) radiation. In the middle is the visible light spectrum, which you perceive as the colours of the rainbow. And at the other end is the infrared spectrum, which you can’t see but can sometimes feel as radiant heat. Solar rays reach the Earth in waves, so each part of the light spectrum is distinguished by its unique wavelength. Ultraviolet light is divided into three types: UVC, UVB and UVA. Ozone blocks UVC, but the other types of ultraviolet light, B and A, penetrate the atmosphere and your skin. UVB rays are what cause sunburn and the resulting skin damage. But, as it turns out, UVB and UVA light therapy (also called “phototherapy”) can be very helpful for psoriasis, because it slows down DNA production, which leads to reduced skin cell turnover. Most major health centres in Canada have specialized clinics where you can receive the exact therapeutic exposure needed to slowly clear the skin of plaques. UVB light therapy has proven beneficial for psoriasis on its own or in combination with other treatments. Since UVA isn’t very effective on its own, it’s often combined with Psoralen, a drug that makes the skin more sensitive to light. The downsides to light therapy are its time demands and a slightly increased risk of developing skin cancers. Typically, you’ll visit the phototherapy clinic two or three times a week for two to three months. When UVB/A radiation penetrates your skin’s outer layers, it damages the DNA contained in the skin cells, which over time can result in premature aging, wrinkles and early cellular changes that could lead to skin cancer. If you’re receiving regular light therapy, you should also have regular skin examinations for personal peace of mind and early detection, especially if you have fair skin that never or rarely tans.

Broadband UVB Light Therapy has proven very effective for treating psoriasis, either on its own or in combination with other medications, commonly coal tar or anthralin but also steroids and calcipotriol, as well as systemic agents. After preparation for exposure, you’ll be asked to stand in a light cabinet, which surrounds you with UVB light. The starting dose of UVB depends on your skin type. You’ll likely be exposed to ultraviolet light for a few seconds and gradually build up to several minutes. Then exposure can be incrementally increased to 20 minutes or more. Once the psoriasis patches respond, the number of your visits can decrease to a maintenance regimen or stop altogether in favour of another maintenance approach. If you burn as a result of treatment, you should immediately notify your doctor or the clinic staff.

UVB rays can harm your eyes, so you’ll be asked to wear special glasses while in the light cabinet. And because UVB can burn your skin, you’ll need to take some basic precautions while receiving therapy:

Use sunscreen to protect such sensitive areas as your lips and nipples during treatment
Men should screen their genitals during treatment to reduce cancer risk
Cover up or use a sunscreen when outdoors to prevent serious sunburn on treatment days
Avoid tanning salons

Your dermatologist may prescribe the Groeckerman Regimen, which combines UVB radiation with coal tar. To make your skin more light sensitive, the tar is applied topically or you take a tar bath before receiving radiation. Afterward, you take a soap-and-water bath to remove the tar. Sometimes you may be asked to come back the following day for another round of UVB radiation, in which case you may be asked to forego the second bath and wear a body stocking overnight to protect your clothes and bedding. The regimen may be messy and inconvenient, but it’s still one of the most effective approaches to clearing your skin.

For particularly resistant and widespread psoriasis, the Ingram Regimen goes one better: The day before UVB treatment, you apply anthralin to the affected areas and then put on a body stocking. The following day at the clinic, you wipe off the anthralin with mineral oil, then take a tar bath. After UVB exposure, you reapply the anthralin and put on the body stocking again. Make sure to thoroughly wash your hands after the therapy session, since anthralin is highly irritating to eyes and unaffected skin, and can be transferred by chance contact. If anything, the Ingram Regimen is messier and more inconvenient than its predecessor, but it, too, is a very effective way to treat psoriasis.

Recently, UVB therapy has been combined with calcipotriol with very good results in a regimen that sees the topical applied after twice weekly exposure. Apart from the convenience compared to the earlier regimens, this combination also allows for a reduction in total UVB exposure, which in turn lowers somewhat the risks of sunburn and skin cancer. UVB has also been used with Tazarotene, which makes the skin more light sensitive. These combination regimens using topical medications and UVB can last up to four weeks. For some of the worst cases of psoriasis, UVB is combined with such systemic agents as Methotrexate, Cyclosprine or retinoids.

Narrowband UVB Light Therapy is a relatively new technology that emits high intensity light waves and avoids UVB wavelengths associated with sunburn, skin cancers and premature aging of the skin. Studies suggest that some patients respond sooner to this precise approach and that the benefits can last longer than conventional UVB therapy. Although often used on its own because it’s so effective, narrow band UVB therapy can be combined with topical therapies.

Psoralen Ultraviolet-A Light Therapy (or PUVA therapy) refers to a treatment approach that capitalizes on UVA radiation by combining it with Psoralen, a UV-sensitizing drug. The combination appears to block cell reproduction, which then slows down the disease process. PUVA requires real commitment; patients usually must come to the clinic 2-3 times a week for 8-12 weeks to see long-lasting results. Increased light sensitivity imposes its own inconveniences. You’ll need to wear UV-protective sunglasses for 24 hours after absorbing Psoralen to offset an increased risk of eye damage. You should also protect your skin against sun exposure and sunburn during PUVA therapy. In addition, Psoralen can often cause upset stomach and nausea. If your psoriasis is localized, there are topical Psoralen creams that you can apply two hours before UVA exposure. For generalized psoriasis, soaking in a Psoralen bath shortly before entering the UVA light chamber is an alternative that spares the stomach. While in the light chamber, you must wear protective goggles to shield your eyes, and your lips and nipples should be protected with zinc oxide ointment. Your genitals must also be covered. At first, your exposure time will be very brief (a matter of seconds) and then gradually increased up to 20 minutes, or as determined by your skin type, clinic staff and your doctor. Skin reactions to PUVA can include itching, sunburn, blistering, freckling and rapid aging of the skin.

Long-term risk of skin cancers also increase, particularly among patients who must repeat PUVA therapy to maintain benefits. To catch early signs of cancer, which can develop many years after beginning PUVA therapy, you should receive a full skin examination by your doctor as part of your annual check-up. Clearance rates for patients undergoing PUVA are very high and make the treatment strategy well worthwhile. Once the psoriasis patches respond, the number of your visits can decrease to a maintenance regimen or stop altogether in favour of another maintenance approach. PUVA has also been successfully combined with topical and systemic medications, which speeds up response to treatment and reduces overall UVA exposure.

If your psoriasis is particularly aggressive or resistant to other treatments, or if you develop severe psoriatic arthritis, your doctor may consider adding a systemic medication to your treatment regimen. These powerful drugs enter the bloodstream, which is why they’re called “systemic,” and have a global effect on various organ systems, the blood, liver and kidneys in particular. Side effects tend to appear either when first starting one of these drugs or after using it for a long time. Close monitoring through blood and urine tests is a must to catch any changes early. While this approach may have its discomforts and hazards, given the clinical circumstances of uncontrolled psoriasis and/or psoriatic arthritis, systemic therapies are an option that must be considered, since they have proven very effective for many patients.

Methotrexate (MTX) is used to treat plaque, pustular and erythrodermic psoriasis and is a mainstay in treating aggressive psoriatic arthritis. Taken once a week (either orally or by injection), the drug interferes with cell division and thus slows down the disease process. It also has an anti-inflammatory effect by deactivating the T cells that infiltrate the skin layers below psoriatic lesions.

Methotrexate is not for everybody. It places a considerable burden on liver and kidney function, so anyone who has other conditions that affect these organs should avoid MTX. People who have impaired immune systems should also avoid MTX since it suppresses immune function and thus leaves them vulnerable to infections. People with diabetes are at high risk of developing liver complications, as are people who are obese, and so should not take MTX. Women who are pregnant, planning a pregnancy or are nursing should never use Methotrexate because of the risk of birth defects.

Alcohol must be avoided when using Methotrexate, since it can amplify the drug’s effects on the liver and could result in scarring (cirrhosis). Indeed, a history of alcohol abuse or ongoing alcohol dependence rules out the possibility of being treated with Methotrexate.

Common side effects that are usually experienced when you begin MTX therapy include gastric distress and nausea, mild hair loss, fatigue and loss of appetite. Occasional short-term side effects include mouth sores, sun sensitivity, low-grade fever, sore throat and muscle aches. Many of these problems are due to a deficiency in folic acid as a result of the Methotrexate and can be offset by taking daily folic acid supplements. Other unwanted effects may require adjusting your dose. You can opt for the injectable form of Methotrexate if nausea and gastric upset persist, although this will entail a weekly clinic visit to receive the injection. You’ll need to protect yourself against sunburn, too, especially if you’re also undergoing UVB or PUVA therapy.

While taking Methotrexate, if you develop a persistent cough, experience a severe headache or discover that you bruise easily, contact your doctor, since these may be signs that could require prompt medical care.

Long-term side effects are usually the result of the drug’s growing toxicity after prolonged use. Risks of damage to the liver, kidneys, lungs and bone marrow increase significantly. As a result, your doctor will want regular follow-up visits and blood and urine tests to monitor for any emerging problems. After several years of Methotrexate therapy, your doctor might order a liver biopsy to confirm the laboratory readings or consider switching to an alternative medication.

There are many drugs that interact badly with Methotrexate, including ASA and other non-steroidal anti-inflammatory drugs, penicillin, barbiturates and the antibiotic trimethoprim sulfamethoxazole. Make sure your doctor and your pharmacist know exactly which medications you take routinely or occasionally. Consult with your doctor or pharmacist before beginning any new medication, prescription or non-prescription.

Cyclosporine is a potent immune system suppressant that was first used to offset the risks of rejection in organ transplant surgery. Until the arrival of biologic agents, Cyclosporine was very much the drug of last resort for severe, unresponsive plaque psoriasis, mainly because of its potential for serious kidney damage with long-term treatment. On the plus side of the equation, however, Cyclosporine works rapidly (sometimes in 4 weeks, and certainly within 8-12 weeks) and is highly effective in most people.

This approach to treating psoriasis is a short-term strategy for gaining control over treatment-resistant symptoms. Taken orally on a daily basis, the dose is based on your weight, and you must faithfully follow the regimen. Laboratory tests to detect a wide array of problems will be routine. And while the benefits of Cyclosporine are likely be significant, your doctor will already be considering other treatment options to maintain those advances. Cyclosporine is usually discontinued after a year to avoid kidney damage, and your doctor will taper your dose once you're passed this clinical milestone. This approach is used to give time for another medication (or combination of therapies) to take effect and to prevent a recurrence of your psoriasis. Common and temporary side effects of Cyclosporine include headaches, inflamed gums, nausea, body hair growth, joint pain, gout, tremor and fatigue. Cyclosporine affects blood potassium levels, as well as levels of serum cholesterol and other fats, so these will be monitored closely.

More serious side effects include kidney damage, which almost always occurs after prolonged use; high blood pressure (in about 1/3 of patients); liver abnormalities; higher risk of infection; and a higher incidence of squamous cell carcinoma among people who received prior PUVA therapy for their psoriasis.

There are many drugs that interact badly with Cyclosporine, including such common ones as non-steroidal anti-inflammatory drugs, antibiotics, oral contraceptives, and Warfarin. The herbal remedy St. John’s wort and grapefruit and grapefruit juice also interfere with Cyclosporine. Make sure your doctor and pharmacist know exactly which medications you take routinely or occasionally. Consult with your doctor or pharmacist before beginning any new medication, prescription or non-prescription.

Acitretin belongs to a class of medications called retinoids. It’s particularly helpful in treating erythrodermic and pustular psoriasis, particularly the form localized on the palms of the hands and soles of the feet. On its own, though, Acitretin is less effective for plaque and guttate psoriasis, so it’s often combined with PUVA for greater benefits. It also works well in combination with topical steroids and calcipotriol. Acitretin helps reduce the rapid turnover of skin cells and permits new skin cells to mature properly. Doctors usually start with a low dose of the drug and then after 1-2 months increase the dose to boost response.

Women who are pregnant or nursing, or who are planning to become pregnant, cannot take Acitretin because the drug causes birth defects and miscarriages. Indeed, to avoid any such possible risks, some doctors will only prescribe it to men or women who are post-menopausal or who have undergone a hysterectomy. Nevertheless, for those women who could become pregnant and who do take Acitretin, a strict protocol of birth control (a combination of two effective methods) must be begun 1 month before starting the drug and followed for 3 years after stopping treatment.

Women who could become pregnant should also avoid alcohol during treatment and for two months afterward. Normally Acitretin is cleared from the body in about three or four weeks, with one notable exception. Alcohol converts Acitretin into Etretinate, another type of retinoid that is stored in fat cells for up to 3 years and that can, like all retinoids, cause birth defects.

Finally, if you take Acitretin, you should not donate blood during treatment, because of the harm a transfusion might cause should a pregnant woman be the recipient. After stopping Acitretin, you would be wise to wait for 3 years to donate blood.

There are other side effects, as well. Commonly, several weeks or so after beginning acitretin, you are likely to experience dryness of the mucous membranes, which results in irritated eyes, nosebleeds, dry mouth, chapped lips and itchy, scaly skin. Also, the skin from the tips of the fingers, as well as from the palms and soles, can peel. Moisturizers and emollients help make these effects tolerable. Often, they clear up on their own after your body has adjusted to the acitretin.

Other frequent side effects include severe headache, blurred vision and nausea and vomiting. Contact your doctor or your pharmacist if you experience these symptoms. Another concern (more of a limiting factor if you already have high cholesterol) is that acitretin increases the levels of triglycerides (cholesterol and other fatty molecules) in the blood, which increases your overall risk of heart attack and stroke. Hair loss is possible, although relatively rare, and is usually reversible once treatment is stopped.

Your blood pressure will be watched closely, and you’ll need to have regular monitoring of your blood triglycerides, as well as your kidney and liver function. Acitretin, doesn’t mix well with certain drugs, including some types of antibiotics, vitamin A or multivitamins containing vitamin A, Methotrexate, Cyclosporine and St. John’s wort. Make sure your doctor and pharmacist know exactly which medications you take routinely or occasionally. Consult with your doctor or pharmacist before beginning any new medication, whether by prescription or non-prescription.

Biologic Treatments

Biologic response modifiers, commonly referred to as biologic agents or simply “biologics”, are a relatively new class of treatment that exploits science’s growing understanding of the body’s immune system. Unlike traditional drugs, which are chemical compounds, biologics are created from specialized live cells that are genetically engineered in the laboratory to produce exact copies of naturally occurring nucleic acids and proteins. Usually, these cell products are key molecules involved in modifying a person’s immune response. Biologics are distinguished by their exquisite precision. In contrast to conventional drugs that can sometimes indiscriminately suppress much of the immune system, biologics target a specific cell receptor or cell signal. This potentially means fewer of the negative side effects associated with conventional psoriasis treatments. Doctors use a number of biologic agents either to turn off the activated T cells in the skin responsible for inflammation and plaque formation, or to block TNF (tumor necrosis factor), an inter-cellular messenger molecule that sets off inflammation. Biologics are administered either by injection or by intravenous infusion, because digestion after oral administration would destroy these specialized proteins before they could enter the bloodstream.

Clinical response to these agents is often significant in terms of clearing plaques and restoring quality of life. Benefits can last a year or longer after completing one or more courses of treatment. Some biologics can also be combined with topical and light therapies.

The most common side effect for certain biologics is mild inflammation at the injection site, which often disappears as therapy progresses. As might be expected from an agent that selectively modifies the immune system, each biologic has its own set of potential hazards and concerns that must be monitored.

Currently, two T-cell blockers (Alefacept and Efalizumab) and three TNF blockers (Etanercept, Infliximab, and Adalimumab) are approved for use in Canada to treat aggressive psoriasis.

T Cell Blockers

Alefacept fuses a human cell receptor with a human antibody to target and block the CD2 receptor on T cells. This calms active T cells and prevents additional T cells from becoming activated. By intervening early in the molecular chain of events that leads to inflammation, the disease’s progress is stopped and the skin plaques begin to heal, while new ones are prevented from occurring. Your doctor will likely administer Alefacept by once weekly injections into muscle tissue for 12 weeks. People often continue to improve after completing a series of injections. Repeat courses may be necessary to achieve maximum benefit. With proper training, self-injection is possible. Ask your doctor about this option. By comparison with other biological agents, Alefacept is relatively slow acting, and it may take 2-3 months before you can see visible improvement. Alefacept combines well with topical steroids, light therapy and Acitretin, all of which can help speed up the healing process. Improvement in psoriasis is significant, and can last for up to a year or more after treatment.

Some people are not good candidates for Alefacept, so discuss with your doctor your medical history and any medications you have taken or are still taking, prescription and non-prescription. Don’t forget to mention any alternative or herbal remedies you're using. Your doctor will rule out this kind of therapy if you are pregnant or nursing, have had or are prone to infections, have had or been exposed to tuberculosis, have HIV/AIDS or another condition that weakens the immune system, are taking medications that suppress the immune system, or have a history of cancer.

Your doctor will stop treatment if you become pregnant, your T cell count drops below a certain level (250 cells/uL), you develop an infection or severe flu-like symptoms and a cough, or if you need to receive a vaccine. Because Alefacept does modify the immune system, your overall potential risk for cancer is theoretically slightly increased.

The most common side effects include redness, swelling and pain at the injection site, fatigue, sore throat and runny nose, nausea and diarrhea, and headaches and chills. You’ll need to have weekly blood tests to watch your white blood cell count. When Alefacept is stopped, there appears to be no “rebound effect,” in which the psoriasis suddenly gets worse. If you self-inject, you’ll need to store the medication in the refrigerator and should allow the vial to warm up for about a half-hour before injection. Once the Alefacept is mixed in liquid form, it’s best to use it immediately. If, for some reason, you’re interrupted, store the mixture in the refrigerator. If you haven’t used it within 4 hours, discard the mixture.

Efalizumab is a monoclonal antibody that selectively binds to a surface protein, called CD11. In doing so, it stops T cells from becoming activated and migrating to the skin, and it seems to inhibit reactivation of T cells in the transitional layers between the dermis and epidermis. As a result, the inflammation and plaques begin to clear up, sometimes in as little as two weeks. Over time there can be significant improvement in the skin signs of psoriasis due to efalizumab.

Efalizumab is injected just under the skin, usually 1 injection a week. The dose is determined by your weight. Clinical trials have shown that if treatment is stopped after 12 weeks, the psoriasis will likely return within 2 months. As a result, Efalizumab needs to be taken continuously to maintain benefits. You can be taught to self-administer the injection. Efalizumab is supplied as a white powder in a disposable vial that should be kept refrigerated (but not frozen) and protected from exposure to light.

Not everyone should take Efalizumab, so discuss with your doctor your medical history and any medications you have taken or are still taking, prescription and non-prescription, including herbal remedies. Your doctor will likely rule out this kind of therapy if you are pregnant or nursing, have had or are prone to infections, have had or been exposed to tuberculosis, have HIV/AIDS or another condition that weakens the immune system, are taking medications that suppress the immune system, or have a history of cancer.

Alert your doctor if you become pregnant, develop an infection or severe flu-like symptoms and a cough, or if you need to receive a vaccine. Mild flu-like symptoms (chills, headaches, low-grade fever) usually disappear by the third injection. If your gums bleed or you develop small red spots on your skin, contact your doctor, since these may be signs of a low platelet count, which affects blood clotting. Because Efalizumab modifies the immune system, your overall potential risk for cancer may theoretically be slightly increased, although clinical studies to date have not demonstrated this.

TNF Blockers

Infliximab is a monoclonal antibody that binds to TNF (tumor necrosis factor), a pro-inflammatory messenger molecule that is found in abnormally high levels in the skin and joints of people who have psoriasis and psoriatic arthritis. Infliximab recognizes and marks for destruction any activated T cells that have already bound with TNF, while also intercepting circulating serum TNF and neutralizing its inflammatory effects. By intervening early in the molecular chain of events that leads to inflammation, the disease’s progress is stopped. Skin plaques begin to heal and new ones are prevented from occurring.

This type of biological therapy requires that you receive Infliximab in clinic by intravenous infusion over two hours. After the first infusion, the next 3 infusions will be scheduled for 2, 6, and 10 weeks later. If this trial goes as expected, producing visible improvement with no serious side effects, you will likely be put on a maintenance regimen of 1 infusion every 8 weeks. Most patients respond very quickly to Infliximab (sometimes after 2 weeks).

This treatment may not be for you if you are pregnant, planning to be or are nursing, have a prior history of heart failure, have had or have been exposed to tuberculosis, have multiple sclerosis or certain other nerve diseases, have uncontrolled diabetes, or have a history of liver disease. Discuss with your doctor your medical history and any medications you have taken or are still taking, prescription and non-prescription, including any alternative or herbal remedies.

Common adverse effects include nausea, abdominal pain, back pain, joint pain, fatigue and headache, usually on the day of or for several days after an infusion.

The suffix, “iximab,” indicates that Infliximab is made from a combination of human and mouse cellular components. This raises the possibility that your immune system might recognize Infliximab as a foreign molecule, which may result in an allergic reaction to the drug. Mild symptoms might be itchiness and hives, joint pain or low-grade fever. Rarely, more severe symptoms might include wheezing, difficulty breathing, changes in blood pressure and hives. In either case, tell your doctor immediately. In rare instances infliximab has been associated with certain neurologic disorders known as demyelinating diseases. Other patients receiving infliximab in combination with the immune-suppressing drugs azathioprine or mercaptopurine, have been reported to develop lymphoma, a form of cancer involving immune cells. This occurrence has been very rare as well.

Because Infliximab modifies the immune system, there is increased risk of developing an infection, particularly for anyone who is already prone to longstanding or recurring infections. There are case reports of tuberculosis and histoplasmosis (another type of lung infection) in some people using TNF blockers. Typically, you’ll be tested for TB before beginning treatment. If you do develop an infection, you will have to stop Infliximab until it is cleared up. Most often, you can begin again.

Etanercept is a TNF receptor fused to an antibody that binds with circulating TNF molecules before they can dock with T cells, thus calming the cellular activity that leads to inflammation and psoriatic plaques. By intervening early in the molecular chain of events that leads to inflammation, the disease’s progress is stopped. Skin plaques begin to heal and new ones are prevented from occurring.

Usually Etanercept is self-administered as twice-weekly injections under the skin for the first 12 weeks, and once-weekly injections thereafter. Your doctor will teach you how to prepare and give yourself an injection.

Improvement should be noticeable after 12 weeks, with many people experiencing very significant improvement in their skin signs of psoriasis. Continuing treatment can lead to additional improvement. Etanercept has been combined successfully with Cyclosporine and Methotrexate.

Not everyone should take Etanercept, so discuss with your doctor your medical history and any medications you have taken or are still taking, prescription and non-prescription, including alternative or herbal remedies. Your doctor will rule out this kind of therapy if you are pregnant or nursing, have had or are prone to infections, have had or been exposed to tuberculosis, have HIV/AIDS or another condition that weakens the immune system, are taking medications that suppress the immune system, have a history of heart failure, have multiple sclerosis or certain other nervous system diseases, have uncontrolled diabetes, have a history of liver disease, or have a history of cancer.

The most common side effects are mild reactions at the injection site (itchiness, redness and swelling), headaches and mild flu-like symptoms (sore throat, cough, low-grade fever, fatigue).

Because Etanercept modifies the immune system, there is increased risk of developing an infection, particularly for anyone who is already prone to longstanding or recurring infections. There are case reports of tuberculosis and histoplasmosis (another type of lung infection) in some people using TNF blockers. Typically, you’ll be tested for TB before beginning treatment. If you do develop an infection, you will have to stop Etanercept until it is cleared up. Most often, you can begin again once it has resolved. In rare instances infliximab has been associated with certain neurologic disorders known as demyelinating diseases. Although an exact cause and effect relationship has not been demonstrated, studies to date have shown a slight, but statistically increased occurrence of lymphoma, a type of immune cell cancer, in patient who have received TNF-blocking drugs such as etanercept.

Adalimumab was approved in January 2008 for use in Canada for the treatment of moderate to severe plaque psoriasis. It was initially used to treat psoriatic arthritis, but after additional testing it has now been approved for psoriasis as well since it can result in significant improvement of this skin disorder. It is injected under the skin every other week.

Adalimumab blocks tumor necrosis factor (TNF), a chemical "messenger" in the immune system that signals other cells to cause inflammation. There is too much TNF in the skin of people with psoriasis and the joints of people with certain types of arthritis. TNF can also lead to increased immune system activity through the activation of immune cells, including T cells. T cells are a type of white blood cell in the body; in psoriasis, once T cells are mistakenly activated, they can trigger inflammation and other immune responses and fuel the development of psoriasis lesions.

Adalimumab helps lower the amount of TNF, thus interrupting the inflammatory cycle of psoriasis and psoriatic arthritis and leading to improvement in symptoms for many people who take it.

Adalimumab should not be taken by people with active serious infections or a history of recurrent infections, a history of heart failure, multiple sclerosis or other similar types of demyelinating neurologic diseases, or by children. Adalimumab is designed to be taken continuously to maintain improvement, and may be prescribed by itself or in combination treatment with methotrexate.

Common side effects, which are generally mild and did not cause most patient to stop taking Adalimumab, include upper respiratory infections, abdominal pain, headache, rash, injection site reactions, and urinary tract infection.

Some Adalimumab patients have reported TB, invasive fungal infections and other serious infections, a few of which have been fatal. However, the infections often presented in patients who were also using other medications that affect the immune system. Adalimumab has also been associated with rare instances of serious demyelinating neurologic disorders and a theoretically slightly increased risk of developing cancer.

To learn about clinical trials that may be underway in Canada related to this skin disorder or disease, check out our Clinical Trials page.

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