Applied directly on the infected areas:
Keratolytics (Dithranol - Vegetable and Mineral Tar – Salicylic Acid)
Help remove scales and prepare patches for other treatments.
A synthetic Vitamin D3 analogue, which inhibits the proliferation of keratinocytes by stimulating their correct maturity with no risk of significant side effects, but for some local irritation.
Another Vitamina D3 analogue that inhibits the proliferation of keratinocytes. It is considered a primary treatment for light-mild psoriasis vulgaris – just like other vitamin D3 derivatives – and can be associated with systemic treatments.
Calcipotriol and Betamethasone dipropionate
This new combination of Calcipotriol 50 μg/g and Betamethasone dipropionate 0.5 mg/g has been developed for the treatment of psoriasis. The former acts mainly on the keratinocytes, whilst the latter acts on the inflammation.
This active metabolite of vitamin D3 is a powerful agent to inhibit the proliferation of keratinocytes. Calcitriol acts on the cutis, blocking keratinocytes differentiation. Several studies have shown it is safe and well tolerated in the treatment of plaque psoriasis involving the most sensitive parts of the body, such as the face, behind the ears, armpits, groins and under the breast.
This retinoid normalises the proliferation of the skin cells responsible for the appearance of spots. It is valid for the treatment of plaque psoriasis and has a good level of safety. Itching and erythema may appear during treatment; very effective if associated with topic cortisone drugs.
These drugs work on the inflammatory element of psoriasis and apparently inhibit cell division. However, they can only be used for short periods in order to avoid side effects such as skin atrophy.
An effective treatment to avoid itching; it has an anti-inflammatory and anti-bacterial action on chronic skin diseases such as light-moderate plaque psoriasis seborrheic dermatitis and eczema. Many studies have shown that Zinc Pyrithione 0.25 % - 0.5 % - 1% is an effective treatment for dandruff. Well-tolerated and effective in removing skin flakes.
This is a new option for the treatment of light-moderate psoriasis in the most sensitive parts of the body. It is the simplest form of silicon, thus it is rapidly absorbed and penetrates well into the skin cells. Nanosan has shown good results on the irritated sites and has an anti-oxidant and anti-inflammatory effect.
Systemic treatments are extremely indicated for the most severe forms of Psoriasis. These treatments can be quite toxic and may also have side effects. Among these drugs we have:
It has a limited use due to its medium-long term risks. It has a great immune-suppressive and anti-inflammatory power.
It works on the immune system by slowing it down. It must be used under strict medical surveillance as it exposes the body to infective diseases.
Oral Retinoids (Etretinate - Acitretin)
They work on the differentiation mechanisms of skin cells and limit tissue inflammation.
Fumarates (fumaric acid esters)
Their benefits have been known for some years and have shown satisfying results. They represent a valid integration to oral drugs foreseen by official protocols. Registered in Germany, but not yet available in Italy.
UVB narrow band.
Narrowband treatments use 311 nm UVB radiations.
PUVA use UVA radiations together with a psoralen. This combination makes the skin more sensitive to this kind of wavelength.
Monochromatic light excimer
This treatment uses radiations with a wavelength of 308 nm; it is performed in hospital and efficacy can be seen only after few treatments. The most common side effects of phototherapy are skin ageing and an increased risk of skin cancer. These treatments require a certain number of weekly visits to hospital or specialised centres.
This tool allows to irradiate only small areas although with great intensity; this makes treatments long and increases the risk of erythematous reactions. The use of an excimer monochromatic light with a non-coherent emission beam seems to have solved the aforementioned problems.
Biologic drugs represent one of the greatest medical innovations of the last few years. Their success is due to their highly selective action that allows most times a great and rapid therapeutic efficacy and low side effects compared to traditional “chemical” treatments. Currently produced biologics are monoclonal antibodies, cytokines (interferons or interleukins), fusion proteins and tissue growth factors.
All these products have the great advantage to act in a selective manner, at different levels and with different methods of actions on the immune processes responsible for the onset of psoriasis. It is a renowned fact that psoriasis involves skin cells such as keratocynes, and the blood cells in charge of defending the immune system, e.g. Lymphocytes T.
The altered “physiological” dialogue between these two kinds of cells brings an imbalance in the synthesis of the lymphocyte T products, with an enormous production of a series of cellular interaction molecules, leading to erythema and scale formation.
The most studied molecules are: Etanercept, Efalizumab*, Infliximab, Adalimumab, Alefacept and Ustekinumab.
Etanercept (Enbrel) is a fusion protein obtained through recombinant DNA techniques of the p75 human receptor of the TNF-alpha factor with the Fc fraction of IgG1 human immunoglobulin. The protein acts as a soluble receptor for the TNF-alpha factor and has a stronger binding affinity for TNF-alpha than those of other soluble receptors. The drug is administered via subcutaneous injections. Etanercept has been registered in EMEA (European Medicines Evaluation Agency) and is indicated for psoriasis, psoriatic arthritis and rheumatoid arthritis. It has been inserted in the Italian NHS list of reimbursable drugs via AIFA (Italian Drug Agency) Decision of 25/06/2005 for the treatment of moderate to severe plaque psoriasis in cases of resistance or failure of conventional systemic treatments.
Efalizumab* (Raptiva) is a drug belonging to the anti-CD11 category. It is a recombinant humanised monoclonal antibody that specifically binds an important lymphocyte T adhesion molecule, fundamental for the three key processes responsible for generating psoriasis, namely the link of lymphocytes to other cells, blood migration towards the derma and the activation of T cells leading to the release of inflammatory cytokines and the proliferation of β-keratins. The drug is registered in EMEA; it is indicated for the treatment of psoriasis and administered via subcutaneous injections. Also this drug is reimbursed by the Italian NHS due to AIFA’s aforementioned decision.
* The Committe fof Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMEA) has analysed the currently available data regarding the safety of Raptiva (efalizumab) and has stated that according to our current knowledge, the benefits of Raptiva are lower than the associated risks. Therefore, EMEA has recommended the suspension of the product.
Infliximab (Ramicade) is a monoclonal antibody, inhibiting the activity of and binding to the Tumor Necrosis Factor (TNF-alpha) with a high specificity and affinity both in soluble and in trans-membrane form. TNF-alpha is pro-inflammatory cytokine highly present in psoriatic lesions and in the joint synovia of patients suffering from psoriatic arthritis. There is great evidence of a correlation between severe skin pathology and the hyperproliferation of erythema and scales, respectively. The drug is administered intravenously and is indicated for psoriasis and psoriatic arthritis. The drug is indicated for the treatment of psoriasis and psoriatic arthritis. AIFA’s decision n.87/2006 established this drug as reimbursed by the Italian NHS; its therapeutic use is for the treatment of moderate to severe plaque psoriasis in cases of resistance or failure of conventional systemic treatments.
Adalimumab (Humira) is a monoclonal antibody targeting the TNF-alpha. The drug is administered subcutaneously in a liquid preparation dose of 40 mg a week. As all anti TNF-alpha, the drug has a highly selective action, i.e. it is able to act exclusively on the activity of the molecule without interfering on the other systems of the body. The drug is indicated for the treatment of psoriatic arthritis and now also for psoriasis.
Alefacet is a LFA-3/IgG1 human fusion protein that acts by blocking the interaction among the cells containing the antigene and the lymphocytes T. Approved by FDA (Food and Drug Administration), the drug is currently the subject of specific European studies/trials.
Ustekinumab (Stelara) is an entirely human IgG1k monoclonal antibody that binds with high affinity and specificity the p40 protein subunit of interleukins IL-12 and IL-23, human cytokines, inhibiting the bond between these cytokines and the specific IL-12Rbeta1 receptor expressed on the surface of immune cells. The drug is indicated for psoriasis and administered subcutaneously every 4 weeks at first and then every 12 weeks. AIFA’s decision of 29 December 2009 established this drug as reimbursed by the Italian NHS.
The "Psocare" project foresees the monitoring in the reference centres indicated in each Italian region of the Biologics registered by EMEA in order to verify their tolerability, efficiency and long-term efficacy.
An example of natural treatment are hydrothermal treatments (Balneotherapy).
Thermal waters have always been a place dedicated to the treatment of chronic diseases, including skin inflammations. They are a valid integration to traditional treatments that foresee the prolonged use of some drugs – mostly cortisone based – especially when one wants to have a so-called drug holiday.
Moreover, SPA therapy prolongs remission terms, reducing the use of topic and systemic treatments in the months following the therapy.
The most commonly used waters for the treatment of psoriasis are Bicarbonate calcium-magnesic and Sulphurous.
The most relevant benefits at skin level are:
- itch soothing
Short term results can be improved by associating phototherapy with UVB narrowband.
The Association has established an agreement with the Comano baths to give to psoriatic patients a natural therapeutic option, just as effective as Balneotherapy.
A very interesting option is the treatment on the Dead Sea. This salt basin is located at about 400 metres below sea level and is considered as the largest natural depression on earth. In a particularly hot dry weather, the sea loses enormous amounts of water due to evaporation; this causes high concentrations of mineral salts such as chlorides of magnesium, calcium, sodium, potassium and bromine. This particular climate is extremely suitable for skin wellness.
These natural treatments are suitable for light forms of psoriasis and – most of all – for those people who do not want to use particularly strong drugs.
It is important to say that although the benefits allow to improve one’s psychological/physical condition and to have a better quality of life, they are not long lasting.