Search

Background Methotrexate is approved by the Food and Drug Ad ministration for the treatment of severe, recalcitrant, and disabling psoriasis that is not adequately responsive to other forms of therapy. It is a systemic immunosuppressant that requires appropriate patient selection, screening laboratory values, and close monitoring before initiation of a maintenance regimen. Purpose This clinical review outlines a practical approach for the use of methotrexate in psoriasis. Methods A review of English-language literature between 1950 and 2010 was conducted, and the results are presented here. Results With close monitoring and appropriate patient selection, methotrexate is often an effective treatment option for moderate to severe psoriasis. Attention to individual patient risk factors and understanding of dosing regimens, contraindications, and “black box” warnings regarding methotrexate use can assist dermatologists in safely prescribing methotrexate for psoriasis treatment. Limitations This practical approach is based on an extensive literature review and the National Psoriasis Foundation and American Academy of Dermatology guidelines formulated after years of clinical practice, newer efficacy trials, and expert consensus regarding management in psoriasis patients. We have additionally incorporated some recommendations from our clinical experience at the University of California-San Francisco Psoriasis Treatment Center as indicated in the text. As always, clinical judgment and risk assessment should be used in selecting appropriate psoriasis patients for methotrexate therapy. Conclusion Methotrexate remains an effective, less expensive, and safe option for psoriasis patients who were previously unresponsive to other forms of therapy.

This clinical review outlines a practical approach to the use of acitretin in the treatment of psoriasis. Acitretin is approved by the Food and Drug Administration for the treatment of adult patients with chronic moderate to severe plaque psoriasis. It is an oral retinoid and is the only systemic agent that is not clinically immunosuppressive; it works primarily by enhancing differentiation and maturation of cells. Side effects associated with this medication are usually mild and manageable; serious adverse events are rare. Therefore, it can be used for long-term maintenance therapy or in combination with other topical or systemic agents and phototherapy.

The ideal repair mechanism for overcoming barrier disruption in atopic dermatitis (AD) needs to completely eliminate microbe and allergen penetration as well as transepidermal water loss. We propose the hydrogel patch as an innovative approach to complete barrier repair. It is composed of an adhesive, thin, flexible, hydrogel layer on an impermeable urethane surface. We conducted a 6-week pilot study with 15 AD patients, who applied the hydrogel patch over one lesion for 6-8 h daily and triamcinolone (TAC) 0.1% cream twice daily to another lesion. Results after 2-week no treatment follow-up showed hydrogel patch had notable efficacy, and comparable to TAC 0.1% cream. Larger studies are needed to validate these results.

Alefacept is a remittive treatment for generalized psoriasis but is rarely used due to its erratic efficacy.To determine if psoriasis plaques will respond to intralesional alefacept and if this predicts a systemic response to intramuscular (IM) alefacept.We describe a 25-week, single-center, open-label study. Patients received weekly intralesional alefacept of increasing concentrations into target plaques for 3 weeks followed by IM injections for 12 weeks and concluded with an observation period of 9 weeks. The psoriasis area and severity index (PASI) was used to assess the efficacy of IM alefacept.Interim results are reported for the first seven patients enrolled. Two patients responded intralesionally to the most dilute 1:100 concentration of alefacept to sterile water and achieved a 59% and 100% improvement in PASI. Five patients did not respond intralesionally to the most dilute form of alefacept and none achieved PASI 75. Two of these five patients did not respond to any concentration and achieved a 26% and 38% improvement in PASI. Limitations to this study include a small sample size and being non-placebo-controlled.Alefacept is effective intralesionally and may predict a systemic response - challenging the concept that biologics must work systemically.

Psoriatic arthritis is a major comorbidity of psoriasis that significantly impairs quality of life and physical function. Because skin lesions classically precede joint symptoms, dermatologists are in a unique position to identify patients at risk for psoriatic arthritis before irreversible joint damage occurs. Here we review the literature to identify the clinical and genetic factors most highly associated with development of psoriatic arthritis, with the goal of assisting dermatologists in risk-stratifying their psoriasis patients.