Transition from methotrexate and cyclosporine to other therapies including retinoids, ultraviolet light and biologic agents in the management of patients with psoriasis

Loading of Coal Tar in Polymeric Nanoparticles as a Potential Therapeutic Modality for Psoriasis

Coal tar (CT) is a commonly used therapeutic agent in psoriasis treatment. CT formulations currently in clinical use have limitations such as toxicity and skin staining properties, leading to patient nonadherence. The purpose of this study was to develop a nanoparticle (NP) formulation for CT based on biocompatible poly(lactide-co-glycolide) (PLGA). CT was entrapped in PLGA NPs by nanoprecipitation, and the resulting NPs were characterized using dynamic light scattering and high-performance liquid chromatography (HPLC) to determine the particle size and CT loading efficiency, respectively. In vitro biocompatibility of the NPs was examined in human dermal fibroblasts. Permeation, washability, and staining experiments were carried out using skin-mimetic Strat-M membranes in Franz diffusion cells. The optimal CT-loaded PLGA NPs achieved 92% loading efficiency and were 133 nm in size with a polydispersity index (PDI) of 0.10 and a zeta potential of -40 mV, promoting colloidal stability during storage. CT NPs significantly reduced the cytotoxicity of crude CT in human dermal fibroblasts, maintaining more than 75% cell viability at the highest concentration tested, whereas an equivalent concentration of CT was associated with 28% viability. Permeation studies showed that only a negligible amount of CT NPs could cross the Strat-M membrane after 24 h, with 97% of the applied dose found accumulated within the membrane. The superiority of CT NPs was further demonstrated by the notably diminished staining ability and enhanced washability compared to those of crude CT. Our findings present a promising CT nanoformulation that can overcome its limitations in the treatment of psoriasis and other skin disorders.

Long-term Safety of Oral Systemic Therapies for Psoriasis: A Comprehensive Review of the Literature

Oral systemic therapies are important treatment options for patients with moderate-to-severe psoriasis, either as monotherapy or in therapy-recalcitrant cases as combination therapy with phototherapy, other oral systemics or biologics. Long-term treatment is needed to maintain sufficient disease control in psoriasis, but continuous use of systemic treatments is limited by adverse events (AEs) and cumulative toxicity risks. The primary aim of this comprehensive literature review was to examine the long-term safety profiles of oral agents commonly used in the treatment of adults with psoriasis. Searches were conducted in EMBASE and PubMed up to November 2018, and 157 relevant publications were included. Long-term treatment with acitretin could be associated with skeletal toxicity and hepatotoxicity, although evidence for skeletal toxicity is mixed and hepatotoxicity is rare, particularly at low doses. Other safety issues include hyperlipidaemia and potential for teratogenicity up to 2-3 years after discontinuation of treatment. There is a paucity of data on long-term treatment with apremilast. Continued exposure to apremilast does not seem to increase the incidence of common AEs, such as gastrointestinal (GI) AEs, upper respiratory tract infections and headache, while the long-term risks for depression, suicidal thoughts and weight loss are unknown. Long-term ciclosporin treatment is associated with renal toxicity, hypertension, non-melanoma skin cancer, neurological AEs and GI AEs. Long-term methotrexate treatment is associated with hepatotoxicity, GI AEs, haematological toxicity, renal toxicity and alopecia. Finally, long-term treatment with fumaric acid esters (FAE) is associated with GI AEs, flushing, lymphocytopenia, proteinuria and elevated liver enzymes. Median drug survival estimates varied considerably: ~  2.9-9.7 months for apremilast; ~ 5.4 months for ciclosporin; ~ 8.6 months for acitretin; ~ 12.1-21.6 months for methotrexate; and ~  54.8 months for FAE. These long-term safety profiles may help to guide clinicians to select the optimal oral systemic treatment for the long-term treatment of psoriasis in adults.

Cyclosporine and psoriasis: 2008 National Psoriasis Foundation Consensus Conference

BACKGROUND

Cyclosporine is a valuable option for the treatment of psoriasis. This report summarizes studies regarding the use of cyclosporine since the last guidelines were published in 1998.

OBJECTIVE

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options. Our aim was to achieve a consensus on new updated guidelines for the use of cyclosporine in the treatment of psoriasis.

METHODS

Reports in the literature were reviewed regarding cyclosporine therapy.

LIMITATIONS

There are few evidence-based studies on the treatment of psoriasis with cyclosporine.

RESULTS

A consensus was achieved on the use of cyclosporine in psoriasis including specific recommendations on dosing, monitoring, and use of cyclosporine in special situations. The consensus received approval from members of the National Psoriasis Foundation Medical Board.

CONCLUSIONS

Cyclosporine is a safe and effective drug for the treatment of psoriasis. It has a particularly useful role in managing psoriatic crises, treating psoriasis unresponsive to other modalities, bridging to other therapies, and treating psoriasis within a rotational scheme of other medications. Appropriate patient selection and monitoring will significantly decrease the risks of side effects.

Strategies for optimizing treatment with efalizumab in moderate to severe psoriasis

With the advent of biological therapies for the treatment of plaque psoriasis, guidance on the usage of these new agents has become necessary. One such agent, efalizumab, a humanized recombinant monoclonal IgG(1) antibody developed to target T-cell-mediated inflammation, provides rapid and sustained efficacy for many psoriasis patients. This article explores the pretreatment, initiation, and treatment phases with efalizumab therapy. In the pretreatment phase, physicians need to assess patients' disease state and educate them about the course of efalizumab treatment. Prior to initiation, physicians need to establish stable disease, ensure an adequate transition or washout of any prior psoriasis therapeutics, and obtain baseline platelet counts. After initiating treatment, both physician and patient must participate in disease monitoring. Patients responding favourably may receive continuous treatment. Those who do not respond to the drug or who experience adverse events should be managed appropriately in order to continue therapy or be transitioned onto another agent. A growing body of clinical evidence, as well as experience from clinical investigators, has provided much insight into the management strategies for patients undergoing treatment with efalizumab.