Current systemic therapies for psoriasis: where are we now?

Can Essential Oils/Botanical Agents Smart-Nanoformulations Be the Winning Cards against Psoriasis?

Although psoriasis remains one of the most devastating inflammatory disorders due to its huge negative impact on patients’ quality of life, new “green” treatment approaches still need to be fully explored. The purpose of this review article is to focus on the utilization of different essential oils and active constituents of herbal botanical origin for the treatment of psoriasis that proved efficacious via both in vitro and in vivo models. The applications of nanotechnology-based formulations which displayed great potential in augmenting the permeation and delivery of these agents is also addressed. Numerous studies have been found which assessed the potential activity of natural botanical agents to overcome psoriasis. Nano-architecture delivery is applied in order to maximize the benefits of their activity, improve properties, and increase patient compliance. This field of natural innovative formulations can be a promising tool to optimize remediation of psoriasis while minimizing adverse effects.

Celastrol inhibits store operated calcium entry and suppresses psoriasis

Introduction: Psoriasis is an inflammatory autoimmune skin disease that is hard to cure and prone to relapse. Currently available global immunosuppressive agents for psoriasis may cause severe side effects, thus it is crucial to identify new therapeutic reagents and druggable signaling pathways for psoriasis. Methods: To check the effects of SOCE inhibitors on psoriasis, we used animal models, biochemical approaches, together with various imaging techniques, including calcium, confocal and FRET imaging. Results and discussion: Store operated calcium (Ca²⁺) entry (SOCE), mediated by STIM1 and Orai1, is crucial for the function of keratinocytes and immune cells, the two major players in psoriasis. Here we showed that a natural compound celastrol is a novel SOCE inhibitor, and it ameliorated the skin lesion and reduced PASI scores in imiquimod-induced psoriasis-like mice. Celastrol dose- and time-dependently inhibited SOCE in HEK cells and HaCaT cells, a keratinocyte cell line. Mechanistically, celastrol inhibited SOCE via its actions both on STIM1 and Orai1. It inhibited Ca²⁺ entry through constitutively-active Orai1 mutants independent of STIM1. Rather than blocking the conformational switch and oligomerization of STIM1 during SOCE activation, celastrol diminished the transition from oligomerized STIM1 into aggregates, thus locking STIM1 in a partially active state. As a result, it abolished the functional coupling between STIM1 and Orai1, diminishing SOCE signals. Overall, our findings identified a new SOCE inhibitor celastrol that suppresses psoriasis, suggesting that SOCE pathway may serve as a new druggable target for treating psoriasis.

The effect of methotrexate monotherapy on treatment-resistant idiopathic granulomatous mastitis patients

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a disease of unknown etiology, involving a chronic inflammatory process, characterized by noncaseating granuloma formation. IGM can mimic a tumor clinically and radiologically. Since we are a tertiary referral center, most of our patients (n = 56, 87.5%) are secondary admissions who have previously had antibiotics and steroid treatments; therefore, we accept these patients as resistant cases. Here, we aim to present our single-center series of 64 patients with resistant IGM who underwent methotrexate monotherapy. To the best of our knowledge, our study includes the highest number of patients described in the literature with IGM who have undergone this treatment.

METHODS

This study included 64 patients, 56 of which were resistant cases, diagnosed with IGM between January 2013 and January 2020 at Istanbul University Cerrahpasa, Cerrahpasa Medical Faculty, General Surgery Breast Outpatient Clinic that were followed-up at least once. These patients were administered oral methotrexate monotherapy 15 mg/week for 24 weeks, and in relapsed cases, the treatment was up to 20 mg/week for 1 year. Folic acid 10 mg/week was given as a supplement to all patients.

RESULTS

Complete recovery was observed in 52 (81.25%) of the 64 patients. Follow-up was discontinued by 4 patients. The dose was increased and the duration of treatment was extended up to 1 year when relapse was observed in 8 patients and complete response was then obtained in these cases. Only 3 patients (4.69%) experienced side effects and were switched to subcutaneous treatment due to nausea.

CONCLUSION

Considering the high patient compliance, low recurrence, minimal side effects, and overall success of the treatment, we believe that methotrexate monotherapy may be used in treatment-resistant IGM patients and may also be the first choice for first-line treatment in the future.

Introduction

Psoriasis is an immune-mediated skin disease in which T cells initiate and maintain the pathogenic process.1 T cells become activated, migrate into the skin, and induce the keratinocyte proliferation associated with the psoriatic phenotype. The activated T cells that infiltrate the skin express the memory phenotype (CD45RO+).2,3 Both CD4+ and CD8+ memory T-cell subtypes are believed to play a role in the pathogenesis of psoriasis. The effectiveness of many traditional therapies for psoriasis (e.g., cyclosporine, methotrexate, psoralen/ultraviolet A light) can be attributed, at least in part, to the potent immunosuppressive effects of these treatments.4,5 Unfortunately, a lack of selective targeting of the immune system by these therapies may result in treatment-limiting side effects.

Simultaneous thrombosis of multiple coronary arteries in a patient with rheumatoid arthritis

We present a case of simultaneous coronary thrombosis of the left main, the left anterior descending artery and the right coronary artery in a patient, recently diagnosed with rheumatoid arthritis.

Non-Invasive Evaluation of Tacalcitol Plus Puva versus Tacalcitol Plus UVB-NB in the Treatment of Psoriasis: “Right-Left Intra-Individual — Pre/Post Comparison Design”

Photochemotherapy with psoralen plus ultraviolet A (PUVA) and phototherapy with UVB narrow band (UVB-NB) are used in the treatment of psoriasis. Numerous studies have shown that the additional administration of either topical or systemic antipsoriatic agents may effectively increase the efficacy of these therapies. This study aimed to compare through objective data the efficacy of topical tacalcitol in combination with PUVA or UVB-NB versus PUVA and UVB-NB monotherapy in the treatment of mild to moderate chronic plaque psoriasis. Modified Psoriasis Area and Severity Index (PASI) score, transepidermal water loss (TEWL) and stratum corneum hydration were used to monitor the restoration of skin barrier in the psoriatic plaques of 40 patients during photochemotherapy. The study was a right-left, intra-individual, pre/post comparison trial. PUVA and UVB-NB treatments were given three times a week. On those plaques localized on the right side of the body tacalcitol ointment was applied once a day, in the evening. Corneometry, TEWL and modified PASI score were used to evaluate the response to the treatment at baseline, one month and two months. Thirty-six of the forty enrolled subjects completed the study. The comparison between combination treatments and the PUVA/UVB-NB monotherapy showed no significant differences with regard to modified PASI index. However, significant differences were recorded with regard to TEWL and corneometry. The combination of tacalcitol plus PUVA or tacalcitol plus UVB-NB restored epidermal barrier functions as well as skin hydration faster than PUVA or UVB-NB monotherapy (TEWL: p=0.0050 and corneometry: p=0.003). The combination of tacalcitol plus UVB-NB allowed a better restoration of skin barrier functions than tacalcitol plus PUVA (p=0.013). In conclusion, the combination of tacalcitol plus PUVA or plus UVB-NB improves the therapeutic result. In addition, the data from TEWL and skin hydration suggest a means in which tacalcitol plus UVB-NB induces a better normalization of skin biophysical parameters.

Therapeutic strategies in psoriasis patients with psoriatic arthritis: focus on new agents

Psoriatic arthritis affects approximately 6-42 % of patients with psoriasis. It is useful for physicians or dermatologists managing psoriasis patients to be aware of how to concurrently manage the joint manifestations, as it is preferable and convenient to use a single agent in such patients. However, only certain therapies are effective for both. Systemic agents, which can be used for both skin and joint manifestations, include methotrexate and ciclosporin. For the group of biologic agents, the tumor necrosis factor inhibitors such as adalimumab, etanercept, infliximab, golimumab and certolizumab are effective. Ustekinumab is a more recently developed agent belonging to the group of anti-IL-12p40 antibodies and has been shown to be efficacious. Newer drugs in the treatment armamentarium that have shown efficacy for both psoriasis and psoriatic arthritis consist of the anti-IL-17 agent, secukinumab, and a phosphodiesterase-4 inhibitor, apremilast. The other anti-IL-17 agents, ixekizumab and brodalumab, as well as the oral Jak inhibitor, tofacitinib, have very limited but promising data. This review paper provides a good overview of the agents that can be used for the concurrent management of skin and joint psoriasis.

Combination therapy with acitretin for psoriasis

Numerous therapies exist for the treatment of psoriasis. A complete understanding of the benefits and potential risks of all therapeutic options is requisite in selecting an appropriate regimen for each patient. This paper examines the effectiveness of combination therapy with acitretin in treating difficult cases of psoriasis, which may require systemic medication or phototherapy. Combination therapy is often more effective than any single agent, as medications with different mechanisms of action work synergistically. Furthermore, using lower doses of two treatments in combination can minimize the potential side effects from a single agent at a higher dose.

Safety and efficacy of early intervention with pimecrolimus cream 1% combined with corticosteroids for major flares in infants and children with atopic dermatitis

OBJECTIVE

To assess early intervention with pimecrolimus combined with corticosteroid (CS) for major flares in patients with severe atopic dermatitis (AD).

METHODS

In this 6-month, double-blind, multicenter, randomized, vehicle-controlled, parallel-group in 35 US centers, 275 children aged 3 months to 11 years with mild to severe AD applied the study medication twice daily at first signs/symptoms of AD. For major flares not controlled with study medication, a mid-potency CS cream replaced the evening study drug for up to 3 weeks. The percentage of subjects with no major flares was the main outcome measure.

RESULTS

Pimecrolimus reduced the major flare incidence and prolonged flare-free intervals. Significantly more pimecrolimus subjects (52%) had no major flares compared with vehicle subjects (34%; p = 0.007). Pimecrolimus significantly delayed the first flare (median, 53 days vs 13 days; p<0.001), and increased the time between flares (median, 31 days vs 15 days). Additionally, there was earlier pruritus improvement (median, day 3 vs day 6; p = 0.034) in the pimecrolimus group, as well as a reduced need for CS by 37% (p = 0.020) [corrected] Adverse events (AEs) incidence and type were comparable between groups. Combination therapy with pimecrolimus used at half the recommended dose did not shorten the mean flare duration or alter the AE profile.

CONCLUSIONS

Early treatment of signs/symptoms of AD with pimecrolimus cream 1% provided an effective steroid-sparing option that reduced the incidence of major flares.

An updated review of acitretin--a systemic retinoid for the treatment of psoriasis

BACKGROUND

Acitretin is a systemic retinoid used for psoriasis. It normalizes cellular differentiation and maturation and is also used as a chemopreventive agent against cutaneous malignancies. However, it is not used frequently because of its side-effect profile.

OBJECTIVE

Safety and efficacy of acitretin was evaluated as monotherapy, as well as in combination with other systemic agents.

METHODS

Medical literature from 2005 to 2008 was reviewed. The most scientifically rigorous clinical trials were selected for Psoriasis Area and Severity Index. Articles were limited to case reports or clinical trials, human subjects and English language journals.

RESULTS/CONCLUSION

Acitretin is effective as monotherapy for pustular and erythrodermic psoriasis and for plaque psoriasis (with other systemic agents). Side effects of acitretin use occur more commonly with high doses. Hence, acitretin is safe and effective for psoriasis.

Perioperative management of medications for psoriasis and psoriatic arthritis: a review for the dermasurgeon

BACKGROUND

Psoriasis affects an estimated 3% of the world's population. Many are on chronic immunosuppressive therapy for the cutaneous and joint manifestations of this disorder. The management of these medications in the perioperative period is controversial. Psoriasis and psoriatic arthritis medications can affect wound healing, hemostasis, and infection risk during cutaneous surgery.

OBJECTIVES

The objective of this article is to provide a critical review of various medications used for care of the psoriatic patient and their potential effect on cutaneous surgical procedures.

CONCLUSIONS

This review summarizes current understanding of wound healing, hemostatic effects, and infectious risks regarding many psoriasis medications including nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, corticosteroids, various immunosuppressants, and biologic response modifiers. Recommendations vary depending on the agent in question, type of procedure, and comorbid conditions in the patient. Caution is advised when using many of the medications reviewed due to lack of human data of their effects in the perioperative period.

Disorders of cell kinetics and differentiation

The kinetics of cells, keratin, and lipids in the skin could provide useful information about skin biology in health and disease. The kinetics of skin cell turnover are of interest for a variety of physiologic and pathologic conditions. There are also uncertainties regarding the extent of keratinocyte turnover in various skin diseases. Hyperproliferation may represent a risk factor for skin cancer and occurs in physiologic conditions such as wound healing.

Steroids versus other immune modulators in the management of allergic dermatoses

PURPOSE OF REVIEW

The classic role of topical and systemic corticosteroids for allergic dermatoses is discussed, with special attention to the impact on the current clinical treatment paradigm by newer systemic and topical therapies. These products are reviewed and recommendations presented on how to effectively assimilate them into clinical practice.

RECENT FINDINGS

Current knowledge about the etiopathogenesis of atopic dermatitis has resulted in drug development focused on agents with less toxicity than current topical and systemic corticosteroids. Some agents with ceramide/cholesterol/acid combinations demonstrate efficacy in restoring the dysfunctional skin barrier of atopic patients. Concerns resulting from the recent Federal Drug Administration announcement regarding a theoretical risk of cancer associated with topical calcineurin inhibitors are also addressed. Novel therapeutic entities are presented.

SUMMARY

Patients seeking relief from atopic dermatitis have historically had few really effective and safe therapeutic options. Topical calcineurin inhibitors represent an exciting new therapy for atopic dermatitis without the side-effect profile associated with topical corticosteroids. Nonsteroidal formulations incorporating glycyrrhetinic acid/telmesteine/Vitis vinifera extract and palmitoylethanolamide as 'active' ingredients recently entered the market, stressing antipruritic, antiinflammatory, and skin barrier repair. This confabulates against previously designed topical therapy paradigms. These new products may be used as monotherapy or alternatives to steroid agents.

Unfavorable cardiovascular risk profiles in untreated and treated psoriasis patients

Psoriasis is a chronic inflammatory skin disease that is associated with an increased cardiovascular risk profile. The systemic inflammation present in psoriasis, various systemic treatments for psoriasis and an increased prevalence of unhealthy life style factors may all contribute to this unfavorable risk profile. The purpose of this article is to provide an overview of what is known about these risk factors in psoriasis, the way they influence the cardiovascular risk of psoriasis patients, and what can be done to reduce this risk. Genetic studies demonstrate that psoriasis and cardiovascular disease share common pathogenic features in which, for example inflammatory cytokines like TNF-alpha and IL-1 play an important role. The chronic inflammation in psoriasis has an unfavorable effect on the cardiovascular risk profile. Multiple cardiovascular risk factors seem to be influenced; the blood pressure, oxidative stress, dyslipidemia, endothelial cell dysfunction, homocysteine levels and blood platelet adhesion. Moreover, classic cardiovascular risk factors like smoking and obesity that have an increased prevalence among patients with psoriasis, indirectly also worsen the cardiovascular risk profile by stimulating the psoriasis activity. Systemic treatments in psoriasis reduce the cardiovascular risk by diminishing the inflammation, but it should be taken into account that most therapies also have adverse cardiovascular effects like dyslipidemia, hyperhomocysteinemia and hypertension. As a consequence preventive measures may be indicated at least during long-term treatments. Prospective research is warranted to accurately estimate the increased cardiovascular risk in psoriasis, to determine the underlying processes and to consider preventive measures according to the absolute risk of cardiovascular disease. The present overview provides data to advice health care providers to pay more attention to the cardiovascular risk profile in psoriasis patients.

Clinical and immunohistochemical assessment of the effect of cyclosporin in keratinocytes and dermal dendrocytes in psoriasis

BACKGROUND

Cyclosporine is a potent immunosupressor, which induces cytokeratin expression pattern changes and dermal dendrocytes number increase.

OBJECTIVES

To evaluate its clinical effect in psoriasis, on keratinocytic proliferation and differentiation, and on dermal dendrocytes proliferation.

METHODS

Thirty patients with psoriasis were treated and evaluated for 8 weeks. Clinical improvement was evaluated by Psoriasis Area and Severity Index (PASI). Biopsies were performed initially and after 8 weeks. Immunohistochemistry [CK markers 10, 14, and 16, and factor XIIIa+ (FXIIIa+)] was performed.

RESULTS

Mean PASI before treatment was 26.32 and 3.71 after. Mean initial and final PASI difference was 22.61 (p < 0.001). Two patients had serum creatinine and six uric acid increase. Before and after treatment, mean numbers per field of dermal dendrocytes were 7.07 and 3.68, respectively. Mean difference was 3.39, with p < 0.001. CK10 immunohistochemical pattern demonstrated recovery of normal expression pattern in 26 patients, while CK14 pattern demonstrated improvement in 21 patients.

CONCLUSIONS

Cyclosporine was effective and safe for psoriasis in low doses, with significant decrease of PASI and dermal dendrocytes number after 8 weeks of therapy. CK10 and 14 pattern changed and, less prominently, CK16 expression. These modifications occur later than the PASI and dermal dendrocytes variation.

The long-term efficacy and safety of new biological therapies for psoriasis

Long-term therapy is often required for psoriasis. This article reviews the most recent long-term clinical data for biological agents that have been approved or for which late-stage development data have been released for the treatment of patients with moderate to severe plaque psoriasis. Efficacy data are available for up to five 12-week courses of alefacept (approximately 60 weeks of therapy), 36 months (144 weeks) of continuous efalizumab, 48 weeks of continuous etanercept, and 50 weeks of bimonthly infliximab. Data sources include publications, product labeling, and posters presented at recent international scientific meetings. Alefacept appears to continue to be efficacious over multiple treatment courses for some responsive patients. The efficacy of efalizumab achieved during the first 12-24 weeks of therapy appears to be maintained or improved through at least 60 weeks of continuous treatment. The efficacy of etanercept appears to be maintained through at least 48 weeks of continuous treatment. Infliximab demonstrates a high response rate soon after initiation, which appears to be maintained through 24 weeks but declines modestly with therapy out to 50 weeks. After 48 weeks, approximately 60% of efalizumab-treated and 45% of etanercept-treated patients remaining on therapy achieved > or =75% improvement from baseline in Psoriasis Area and Severity Index, as did 70.5% of infliximab patients who did not miss more than two infusions. Safety data suggest that these agents may be used for long-term administration. Long-term data from psoriasis trials continue to accumulate. Recent data suggest that biological therapies have efficacy and safety profiles suitable for the long-term treatment of patients with moderate to severe psoriasis.

Therapeutic options in the treatment of psoriasis and atopic dermatitis

A variety of therapeutic options are available to treat psoriasis and atopic dermatitis (AD). Local agents typically are used to treat localized and milder forms of disease, whereas phototherapy and systemic agents are used for more generalized and severe disease. Various combinations and sequences of topical or systemic therapies, or both, have been utilized in the treatment of psoriasis and, less frequently, of AD. Conventional systemic therapies for psoriasis, such as corticosteroids, oral calcineurin inhibitors, antimetabolites, and retinoids, are limited by their propensity to cause serious side effects. More recently, a number of immunobiologic agents, such as monoclonal antibodies, recombinant cytokines, and fusion proteins, have been approved by the Food and Drug Administration or are undergoing development as systemic antipsoriatic treatments. In many of these categories, a number of exciting new therapies are in development that may augment the existing armamentarium available to clinicians for the treatment of inflammatory skin diseases.

A clinician's paradigm in the treatment of psoriasis

Psoriasis is a chronically recurring inflammatory disease that affects the skin, scalp, and joints. It ranges in severity from mild to severe, and patients with moderate to severe disease experience significant deterioration in quality of life. The goals of psoriasis treatment are to gain initial and rapid control of the disease process, decrease the percentage of body surface area involved, decrease plaque lesions, achieve and maintain long-term remission, minimize adverse events, and improve patient quality of life. Therapy varies depending on disease severity and spread and will shift from control of acute flares to long-term maintenance. Topical treatment for mild psoriasis includes the use of topical corticosteroids, calcipotriene, tazarotene, topical tars, anthralin, and keratolytics. Treatment of moderate to severe psoriasis includes systemic therapies, such as methotrexate, acitretin, cyclosporine, and biologic agents. Treatment can be effected using combination, rotational, or sequential regimens. Treatment algorithms developed by a 2002 consensus conference are described. Because some degree of therapy will always be necessary, ranging from maintenance of long-term remission to control of acute psoriasis flares, each patient requires an individualized plan.

Psoriasis: a fresh look

Psoriasis is a disease characterized by scaly skin lesions secondary to keratinocyte hyperplasia. The presence of active T cells in the lesions, experimental observations on disease transfer, and therapeutic efficacy of specific immunosuppressive drugs have led to the identification of the activated T lymphocyte as the primary factor for keratinocyte stimulation. Understanding the pathways of pathogenesis is fundamental in evolving therapies for intervention at different points in the pathogenic model and for curtailing the process. Advances in biotechnological methods have helped to create designer molecules and proteins that specifically recognize target receptors and chemicals that modify their actions. These drugs, termed "biologic response modifiers," are now being studied as specific immunosuppressive agents producing different T-cell and cytokine effects in psoriasis.

[Clinical and histopathological improvement of psoriasis in patients with osteoarthritis treated with chondroitin sulfate: report of 3 cases]

BACKGROUND AND OBJECTIVE

After prescribing chrondroitin sulfate for the symptomatic treatment of osteoarthritis, it has been observed that some patients with concomitant psoriasis experience a marked improvement of skin lesions. We describe the clinical and histopathological results of the erythematous and desquamative plaques of three patients with osteoarthritis and psoriasis treated with chondroitin sulfate.

PATIENTS AND METHOD

Three adult patients with bilateral knee osteoarthritis and long-standing psoriasis characterized by extensive erythematous, desquamative, and hyperkeratotic plaques, which were resistant to different treatment modalities, received 800 mg/day of chondroitin sulfate during two months. Skin biopsies were obtained before and after treatment.

RESULTS

All three patients presented a marked clinical improvement in both pathologies. In addition to a decrease in the thickness of the epidermis (total epidermal thickness, maximal thickness from the basal layer to the beginning of the corneal layer, and maximal thickness of the corneal layer), a decrease in the number of keratinocytes in the proliferative phase, a decrease in the degree of psoriatic activity, and a substitution of parakeratotic keratinization by orthokeratotic keratinization were observed.

CONCLUSIONS

The administration of chrondroitin sulfate resulted in a significant clinical and histological improvement of the psoriatic lesions. The confirmation of these preliminary results in future clinical trials could represent an important advance in the therapeutic armamentarium of patients with psoriasis given the excellent safety profile of this drug.

Differential regulation of Cu, Zn- and Mn-superoxide dismutases by retinoic acid in normal and psoriatic human fibroblasts

Superoxide dismutases' (SODs) expression is altered in several diseases including Alzheimer, atherosclerosis, cancer and psoriasis. Previously, we reported a marked increase in Mn-SOD and Cu,Zn-SOD functional activity in human dermal psoriatic fibroblasts. As retinoic acid (RA) has been used in the treatment of psoriasis and a mechanism for its beneficial effects is not understood, we investigated the effects of RA on SOD mRNA and protein expression levels in human normal and psoriatic fibroblasts. Prior to RA exposure, Cu,Zn-SOD protein and mRNA levels were similar in normal compared to psoriatic fibroblasts while Mn-SOD protein and mRNA levels were increased in psoriatic cells. However, in contrast to normal fibroblasts, exposure of psoriatic fibroblasts to 1 microM RA down-regulated Mn-SOD mRNA, and also decreased Mn-SOD activity by approximately 80% with no change in Mn-SOD protein levels. In contrast, Cu,Zn-SOD protein and enzymatic activity were modestly reduced by RA treatment in both normal and psoriatic fibroblasts. Furthermore, RA treatment of psoriatic fibroblasts also caused a decrease in Cu,Zn-SOD steady-state mRNA levels. These results indicate that RA can serve as a regulatory agent to down-regulate the steady-state levels of both Mn-SOD and Cu,Zn-SOD in psoriatic cells. These findings offer a new model for the antiinflammatory activity of RA when used in the treatment of psoriasis.

Biologics in combination with nonbiologics: efficacy and safety

The mechanisms of action of biologic therapies differ from the currently used systemic therapies by attacking specific steps in the pathogenesis pathway of psoriasis. Preliminary data show that combination therapy using biologics may allow for improved therapeutic efficacy with fewer side effects, including decreased risk of hepatotoxicity and nephrotoxicity commonly associated with the most widely used systemic agents, methotrexate, and cyclosporine. However, some concerns have been raised regarding the increased immunosuppression, increased risk of infection, potential for development of certain types of malignancy, as well as the significant increased cost of therapy. Both potential benefits and toxicities of combination therapy will be reviewed here. Long-term clinical studies are warranted to more accurately quantify the risks and benefits associated with combination therapy. The role of combination therapy will continue to be refined over the next few years to maximize its potential in the treatment of resistant psoriasis.

Biological therapies in the systemic management of psoriasis: International Consensus Conference

Psoriasis is a chronic, immune-mediated disorder that usually requires long-term treatment for control. Approximately 25% of patients have moderate to severe disease and require phototherapy, systemic therapy or both. Despite the availability of numerous therapeutic options, the long-term management of psoriasis can be complicated by treatment-related limitations. With advances in molecular research and technology, several biological therapies are in various stages of development and approval for psoriasis. Biological therapies are designed to modulate key steps in the pathogenesis of psoriasis. Collectively, biologicals have been evaluated in thousands of patients with psoriasis and have demonstrated significant benefit with favourable safety and tolerability profiles. The limitations of current psoriasis therapies, the value of biological therapies for psoriasis, and guidance regarding the incorporation of biological therapies into clinical practice are discussed.

Tratamento sistêmico da psoríase - Parte I: metotrexato e acitretina

Embora a fisiopatologia da psoríase ainda não esteja totalmente esclarecida e permaneçam dúvidas quanto à natureza dos antígenos que levam à ativação do linfócito T e quanto ao papel dos mecanismos reguladores dos surtos e da resolução da inflamação, são inegáveis os avanços terapêuticos das últimas décadas. Além do surgimento de novos medicamentos, a melhor utilização de tratamentos clássicos e a valorização do impacto da terapêutica na qualidade de vida dos pacientes têm contribuído para a diminuição dos índices de morbidade da doença. Este artigo de EMC-D aborda a utilização de metotrexato e acitretina no tratamento da psoríase. A utilização de outros imunomoduladores e de terapias biológicas será objeto de próximo capítulo.