[|Although the distinction is clear in most
patients, the question arises when the acute treatment ends and maintenance
starts in patients with incomplete responses to acute treatments. Prolonged use
of acute treatments is perhaps more reality than exception? It may be helpful
to define the acute phase as a period of time, which is reasonable to induce a
remission: for example 8 weeks. The patient will recognise this as a reasonable
time frame to be compliant. If a treatment is not successful within that
period, we have to call it a failure, stop that treatment and try another
treatment as acute treatment and define again a time frame of 8 weeks. In case
the patient did not respond completely or in case we expect that the patients
will have a fast relapse we need to give an active treatment to maintain the
improvement reached and we can call that a maintenance phase and set again the
time frame for months or years.|auteur197]
It consists of a clearing phase followed by a maintenance phase. The aim of the clearing phase is to get rid of the lesions and the aim of the maintenance phase is to avoid them to relapse.
As a rule, maintenance phase must be very prolonged, since modifications in the dermal capillaries remain extremely sizable, even six months after clearance. Without any rigorous study to demonstrate it, it is still worth bearing in mind that one year of maintenance therapy gives the patient a greater chance of returning to his situation before the first psoriasis attack. This aim should be striven specially if the psoriasis is recent.
This “clearing phase/maintenance phase” strategy may be enacted with topical treatments, wherever usable (limited and stable psoriasis) and sufficiently effective. These topical treatments include fair skin moisturizing. Strength 4 topical steroids are efficient for the clearing phase. Vitamin D3 derivatives can be used indefinitely when efficient. For some patients, alternation between topical steroids and vitamin D3 derivatives is the most convenient maintenance treatment.
The strategy most often adopted as systemic treatment is to start off with PUVA therapy. If relapse is too fast after PUVA therapy, start on acitretine or etretinate, adopting a strategy of progressively increasing doses. Once the maximum well-tolerated dose has been reached for three months, a number of situations may be encountered:
- a) Progressive improvement and hence continuation of treatment until the maximum effect is obtained. If the result is good, acitretine can be used indefinitely, adding UVB TL01 in the case of flare.
- b) Insufficient improvement. In this case, the clearing phase must be resumed, for instance phototherapy and/or topical treatment. After this, retinoids are resumed in the hope to avoid relapses. It should be noted that retinoids are much more effective in maintenance therapy in patients who clear rapidly on PUVA therapy (in less than 18 sessions).
[There is a new strategy being developed at the moment: the combination of UVB TL01 phototherapy or broad-spectrum UVB with acitretine.|This is a well-written chapter. It is, I believe, slightly outdated, ie you state that there is a “new strategy being developed at the moment: the combination of UVB TL01 phototherapy or broad-spectrum UVB with…retinoids.” This is certainly not a new form of therapy!|auteur215] Given the milder aggressiveness of UVB in comparison to PUVA, this treatment is used by some people in the clearing phase and in the maintenance phase. We do not know the maximum cumulative UVB radiation doses not to be exceeded, and in some countries patients are treated with UVB TL01 once a week and small doses of retinoids as a maintenance long-term treatment.
- c) Failure of phototherapy and retinoids. Methotrexate and cyclosporine are discussed. Methotrexate can be used over the long-term or as intermittent treatment, whereas cyclosporine is being used more and more as a short-term of four to five months, to “turn a corner” or to keep an attack in check.
This classic therapeutic strategy is an interesting one to be aware of but remains unfortunately rather theoretical, since even though the clearing phase improves very frequently the quality of life it does rarely clear the lesions completely. Therapists find themselves confronted thus with a difficult situation to manage, an apparently never-ending clearing phase.
All topical treatments may be pursued indefinitely with the exception of topical corticotherapy. Among the systemic treatments, Soriatane/Neotigason may be continued for an extremely long time, if useful, properly monitored and well tolerated. The same goes for methotrexate, as long as hepatic fibrosis can be monitored non-invasively. Broad-spectrum UVB phototherapy or TL01 can probably be used in a very prolonged fashion, but we have no criteria for stipulating the reasonable maximum duration. PUVA therapy has a cumulative toxicity that limits its use. Over the long run, cyclosporine is well tolerated only by some 5% of patients. In order to avoid reaching the toxic cumulative dose for the kidneys, short, intermittent cures are preferred, though without slackening off the monitoring.
In fact, the main point of optimal psoriasis management is to adapt the treatment to the patient’s needs. Psoriasis treatment is the prototype of the “tailored medicine”. We must assess the quality of life of each patient taking into account the reactions to treatments, the biological and psychological tolerance and the co-morbidities Thus, such thing as an algorithm does not exist in psoriasis treatment.
- 2019/10/29 Focus on...World Psoriasis Day 2019
- 2019/08/12 Focus on...Latin American Clinical Practice Guidelines on the Systemic Treatment of Psoriasis
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News from the web office
- 2017/06/05PIN becomes SPIN - Skin Inflammation & Psoriasis International Network
- 2016/10/29PSO 2016 Congress - Webcasts Available!
- 2016/05/26PIN Survey on Phototherapy
- 2016/02/20PIN Study on Therapeutic Patient Education
- 2016/02/19World Directory of Psoriasis Medical Resources - February 2016 Update
- 2019/04/18 Focus on...SPIN Congress 2019 in Paris coming soon
- 2018/07/16SPIN Symposium at the Spring continental meeting - Tehran, 25-27 April 2018
- 2018/02/222nd National Meeting of the Egyptian Society for Psoriasis
- 2018/02/211st Psoriasis Symposium - Sarajevo 2017
- 2017/06/2815th São Paulo Meeting of Psoriasis and Vitiligo
News from medical groups
- 2018/04/183rd Turkish National Psoriasis Symposium
- 2017/06/21Brazilian Center for Psoriasis Studies joins SPIN!
- 2017/06/21Costa Rica Psoriasis Group - Meet them!
- 2017/02/02Works of the 1st Senegalese Psoriasis Day published!
- 2016/07/29Swiss S1 Guidelines for Systemic treatment of psoriasis vulgaris
News from patients associations
- 2017/02/08France Psoriasis - 2016 World Psoriasis Day
- 2016/05/26Senegal Patients Association joins PIN!
- 2015/08/04Epidermia Greece: a new partner association of PIN
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- 2015/04/09AEPSO Argentina launches digital map to find people with psoriasis in the country
Recent publications on Psoriasis and Atopic Dermatitis
Our ambition in a changing landscape of psoriasis treatments.
J Dermatolog Treat. 2020 Mar , 31, (2):105-107.
CARD14/CARMA2sh and TANK differentially regulate poly(I:C)-induced inflammatory reaction in keratinocytes.
J. Cell. Physiol.. 2020 Mar , 235, (3):1895-1902.
CARD14/CARMA2sh (CARMA2sh) is a scaffold protein whose mutations are associated with the onset of human genetic psoriasis and other inflammatory skin disorders. Here we show that the immunomodulatory adapter protein TRAF family member-associated NF-κB activator (TANK) forms a complex with CARMA2sh and MALT1 in a human keratinocytic cell line. We also show that CARMA2 and TANK are individually required to activate the nuclear factor κB (NF-κB) response following exposure to (...)see on pubmed
Prohibitin 1 interacts with signal transducer and activator of transcription 3 in T-helper 17 cells.
Immunol. Lett.. 2020 Mar , 219:8-14.
T-helper 17 (Th17) cells are involved in the occurrence and development of several inflammation-associated diseases. Interleukin (IL)-17, the main cytokine secreted by differentiated Th17 cells, mediates immunoreactions and plays important roles in immunological diseases, including psoriasis, rheumatic arthritis, and inflammatory bowel disease. The maturation and stabilization of the differentiated Th17 cell phenotype are associated with the expression of IL-17A, which is induced by the (...)see on pubmed
Off-label studies on apremilast in dermatology: a review.
J Dermatolog Treat. 2020 Mar , 31, (2):131-140.
Apremilast is a phosphodiesterase-4 inhibitor FDA approved for psoriatic arthritis and moderate to severe plaque psoriasis. In recent years, multiple studies have suggested other potential uses for apremilast in dermatology. A summary of these various studies will be a valuable aid to dermatologists considering apremilast for an alternative indication. The PubMed/MEDLINE and ClinicalTrials.gov databases were queried with the term 'apremilast,' with results manually screened to identify (...)see on pubmed
Atopic dermatitis induces anxiety- and depressive-like behaviors with concomitant neuronal adaptations in brain reward circuits in mice.
Prog. Neuropsychopharmacol. Biol. Psychiatry. 2020 Mar 02, 98:109818.
Clinically, it has been reported that atopic dermatitis (AD) has been linked with negative emotional problems such as depression and anxiety, thereby reducing the quality of life, but little is known about the molecular mechanism that underlies AD-associated emotional impairments. We sought to determine whether AD could induce anxiety- and depressive-like symptoms in mice and to identify pertinent signaling changes in brain reward circuitry. AD-like lesions were induced by the repeated (...)see on pubmed
Efficacy and safety of indigo naturalis ointment in Treating Atopic Dermatitis: A randomized clinical trial.
J Ethnopharmacol. 2020 Mar 25, 250:112477.
Indigo naturalis, a herbal medicine with a history of use dating back to ancient times, may be a good alternative topical treatment for atopic dermatitis (AD).see on pubmed