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Disease & Conditions >>> Psoriasis Articles & News

Beating Severe Psoriasis

 Psoriasis Free For Life

Approximately 10 million people in the United States live with psoriasis, a chronic skin condition that causes scaly, itchy and sometimes painful patches on the body's outer layer of skin. For some the condition is simply irritating and easily managed with topical treatments. For those with moderate to severe psoriasis, the disease can be debilitating. Not only is it painful, it can cause loss of work and limit a person's ability to move freely and participate in physical activities. Psoriasis can also have a devastating effect on self-esteem and social relationships.

Doctors once believed that psoriasis was a chronic disease of the body's epidermis, or the outer layer of skin. But in 1979, doctors found that when people who happen to have psoriasis received a drug used to suppress the immune system as a treatment for another illness, their psoriasis symptoms improved. What had been thought of as a simple disorder of the skin had turned out to be a problem of the immune system.

This knowledge has led to a radical change in the way some cases of psoriasis are treated. Systemic drugs designed to target faulty signals in the immune response are resulting in fewer side effects, and longer remission periods than any treatments before. According to psoriasis expert Dr. David Pariser, professor of dermatology at Eastern Virginia School of Medicine, these drugs, called biologics, are offering new hope to long-time sufferers of the disease. Below, he talks about quality of life issues among those with moderate to severe psoriasis, and treatments past and present.

What causes psoriasis?
One of the exciting new developments in our knowledge about psoriasis is that it is a disorder of immunity. Specifically, it's a disorder of the T-cells, which are a specific blood cell responsible for the development of allergic responses in the skin. In people with psoriasis, the T-cells become overactive and over-responsive.

There are different degrees of this disease. What constitutes moderate to severe psoriasis?
People with moderate psoriasis are affected on more than 10 percent of their body. If someone has psoriasis on their palms and soles and can't walk or use their hands, that would constitute moderate to severe as well. People with severe psoriasis are affected in over 20 percent to 25 percent of their body.

How does having psoriasis affect a person's quality of life?
There have been a number of studies of quality of life among patients with psoriasis, and they reveal serious compromises. First, there is the physical problem of having sore, itchy, cracky plaques of psoriasis. If you have psoriasis on the palms or on the feet, you may not be able to work or walk, which is of course terribly disabling. There are also severe psychological and social aspects of having psoriasis. Some people feel terribly rejected and conspicuous. Perhaps a child is asked to leave a public swimming pool, or an adult is unable to obtain a job because of his or her appearance. I had a patient who was a food service worker who was discharged from his job because his boss was afraid that the flakes of psoriasis were going to get into people's food.

Studies have also shown that self-esteem suffers as a result of psoriasis. A patient's personal, intimate and sexual relations are very clearly affected by psoriasis, and this is a tremendous quality of life issue for many people. We're treating a disability here, not just some cosmetic problem.

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What treatments are available for moderate to severe psoriasis?
For the last eight or ten years, medications for moderate to severe psoriasis have included systemic medications, such as cyclosporin and methotrexate. Both of these work very well, but are associated with severe organ toxicity.

Another treatment for moderate to severe psoriasis has been a form of light treatment called PUVA, which works well, but is inconvenient. Patients have to come into the office sometimes two or three times a week for extended periods of time, and PUVA has side effects as well.

So the latest news in treatment for moderate to severe psoriasis is really very good news. It's a new class of biologic drugs specifically developed and engineered to treat psoriasis by targeting the defective immune response. They block the interaction between the T-cell and another cell in the body called the antigen-presenting cell, which is ultimately responsible for the development of the lesions that we see in patients with psoriasis.

Biologics can also be used to treat psoriatic arthritis, which is a specific type of arthritis that affects one out of five people with psoriasis. They are also used in the treatment of rheumatoid arthritis and Crohn's disease, which is an gastrointestinal disease.

Why must they be delivered by injection instead of in pill-form?
The biologics are large and complex molecules, and they would be digested if taken orally, so there is no currently available oral form of any of the biologics. They are all delivered via injection. Enbrel, approved to treat psoriatic arthritis, is administered by the patient subcutaneously twice a week. Remicade, which is used in the treatment of psoriatic and rheumatoid arthritis, is administered in the physician's office by intravenous infusion over a period of two to three hours. Amevive, currently the only drug approved expressly for the treatment of psoriasis, is given via injection once weekly in the physician's office followed by 12 weeks of no treatment. There are several more biologics that are coming down the research pipeline, which will likely be approved at a later time for treatment of psoriasis. And this will give both physicians and their patients a wider choice of medications to treat the disease.

Are there any side effects with the biologics?
From what we've seen in clinical trials, they all appear to be very safe drugs. Still, any time you administer a potent agent to a patient, there always is a possibility of some side effects and some adverse reaction. But think of it in the context of the patient who has been on cyclosporin, one of the older psoriasis medications. We know, for instance, that cyclosporin causes kidney damage. We know that cyclosporin may cause increased blood pressure and other side effects. And we know that methotrexate—taken long enough—produces liver damage. We know that we're damaging internal organs with these drugs. With the biologics, it does not appear that we are doing that kind of damage.

How do biologics compare in terms of how quickly they take effect?
Most patients who are going to be considered for biologic therapy will have taken cyclosporin or methotrexate at some point. Biologics may not work quite as quickly as methotrexate and certainly not as quickly as cyclosporin, but it may give a longer response in the end. Athough they are not a cure, remissions may last a year, even longer, when no medication would be needed.

Does the development of these new medications represent an important time in the treatment of psoriasis?
It is an exciting new day for both patients and the physicians who treat them. It's been a long time since we've had anything new in the world of psoriasis treatment, particularly something which appears to be as effective as this. It is my hope that in the long run, biologics will prove to be as safe as they've been in clinical trials. I have no reason to believe that they won't, but only time will tell. Certainly for now, biologics represent a paradigm shift in psoriasis treatment, and a significant improvement for patients who suffer with this severe disease.

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