Psoriasis Treatments

There are a number of different treatments for psoriasis:  biologics, oral medications, phototherapy, and goeckerman

BIOLOGICS

Below are the FDA approved biologics for the use of psoriasis

TNF-inhibitors

  1. Etanercept (Enbrel®)
    1. This medication has been in the market for > 15 years and is considered as the safest biologic.
    2. usually comes in prefilled syringe, sure-click pen, or original powder
    3. When starting this medication, you need to be screened for tuberculosis (PPD/Quantiferon gold test), hepatitis B and C, blood count (CBC), and liver function enzymes (AST/ALT).
    4. The usual starting dose is 50 mg twice a week for the first 3 months and then 50 mg once a week thereafter
    5. Common side effects include pain or redness at the site of injection, minor infections (cold, flu, sinusitis, etc.)  Please inform your doctor when you have infections.  Depending on the severity of the infection, he/she may want to have you hold off on this medication until you recover.
    6. Pregnancy safe
    7. The usual follow up time is every 3 months.
    8. While on this medication, your dermatologist will ask you to do yearly blood test (same as screening lab tests).

 

  1. Adalimumab (Humira®)
    1. This medication usually comes in prefilled syringe or sure-click pen.
    2. When starting this medication, you need to be screened for tuberculosis (PPD/Quantiferon gold test), hepatitis B and C, blood count (CBC), and liver function enzymes (AST/ALT).
    3. The usual starting dose is 80 mg on Week 0, 40 mg on Week 1 and then 40 mg every other week thereafter
    4. Common side effects include pain or redness at the site of injection, minor infections (cold, flu, sinusitis, etc).  It may increase risk of tuberculosis and/or other granulomatous infections.  Please inform your doctor when you have infections.  Depending on the severity of the infection, he/she may want to have you hold off on this medication until you recover.
    5. The usual follow up time is every 3 months.
    6. While on this medication, your dermatologist will ask you to do yearly blood test (same as screening lab tests).

 

  1. Infliximab (Remicade®)
    1. This medication is administered through your vein (IV)
    2. It is one of the most efficacious biologics but has limited use because it is administered through the vein.  Most dermatology clinic does not offer this medication to patients.
    3. It has the risk of anaphylaxis and known to lose efficacy over time.
    4. The dose is weight based at 5 mg/kg intravenously at 0, 2, 6 weeks and then every 8 weeks.

Interleukins 12/23

  1. Ustekinumab (Stelara®)
    1. This medication comes in prefilled syringe
    2. When starting this medication, you need to be screened for tuberculosis (PPD/Quantiferon gold test), hepatitis B and C, blood count (CBC), and liver function enzymes (AST/ALT).
    3. The dose is weight based.  If you are 220 lbs or less, the dose is 45 mg.  If you are over 220 lbs, then the dose is 90 mg.
    4. The usual starting dose is given on Week 0, Week 4, and then every 3 months
    5. Common side effects include pain or redness at the site of injection, minor infections (cold, flu, sinusitis, etc).  It may increase risk of tuberculosis and/or other granulomatous infections.  Please inform your doctor when you have infections.  Depending on the severity of the infection, he/she may want to have you hold off on this medication until you recover.
    6. The usual follow up time is every 3 months.
    7. While on this medication, your dermatologist will ask you to do yearly blood test (same as screening lab tests).

 

ORAL SYSTEMIC MEDICATIONS

 

  1. 1.       Cyclosporine (Neoral®)
    1. This medication is very effective with fast results; however, your dermatologist will decide whether this medication is appropriate for you.
    2. Please make sure you ask the pharmacist to give you Neoral® or “modified cyclosporine” because it is more effective than the regular cyclosporine.
    3. Before starting this medication, it is important to do baseline labs (creatinine, complete blood count, potassium, magnesium, uric acid, lipid panel, AST/ALT) and a blood pressure check.
    4. Please do not use this medication if you have uncontrolled high blood pressure with diastolic blood pressure > 90 mmHg or kidney disease.
    5. Common side effects include :

i.      Possible damage to the kidney

ii.      High blood pressure

iii.      Tingling sensation to your fingers or toes

iv.      Increased sensation (hot/cold)

v.      Hair growth

vi.      Headaches

vii.      Nausea

6. According to the international guidelines, this medication cannot be                       used for more than 2 years.  In the United States, the FDA recommends 1-year limit at a time.  The time between each use is not officially defined, but it is usually > 3 months.

7. The dose is weight based 5mg/kg divided in twice daily or three times a day

i.      It comes in 25 mg, 50 mg, and 100 mg tablets

ii.      For petite, non-obese patients à use medium dose 3 mg/kg/day

iii.      For tall, heavier set patients à use higher dose 5 mg/kg/day

iv.      The maximum dose is 5 mg/kg/day

  1. Follow up is usually 2 weeks, then 4 weeks, and then every 6 weeks.  Your dermatologist will ask you to do lab test before your next visit
  1. 2.       Methotrexate
    1. Traditionally, this medication is usually used in conjunction with a TNF inhibitor to prevent “biologic fatigue,” a condition in which a biologic (eg, TNF inhibitor) loses efficacy over time.
    2. If you are planning to become pregnant, please DO NOT use this medication.  Women who are menstruating needs to use effective birth control.  Both men and women should not try to conceive until 3 months after stopping the medication.
    3. Before starting this medication, you will be screened for liver enzymes, blood count, kidney function, and hepatitis B and C.
    4.  Common side effects include:  liver damage, bone marrow suppression, stomach upset, nausea, and fatigue.  There is a black box warning for lymphoma and pneumonitis but incidence is very low.
    5. The medication comes in 2.5 mg tabs

i.      Before you start, a test dose of 5 mg will be given to you with screening lab forms.  Kidney function is repeated after one week of the test dose.  The purpose of a test dose is to screen for bone marrow suppression and liver inflammation.

ii.      This medication is taken once a week

iii.      The dose is usually titrated up slowly as tolerated

iv.      Your dermatologist will give you specific instruction on when to go up on the dose

v.      A liver biopsy is recommended after you have accumulated

  1. A total of 3.5 – 4 g if you do not have risks for hepatitis
  2. A total of 1 – 1.5 g if you have risk factors for hepatitis
  3. Follow up visit with your dermatologist is every 6 weeks.  Please do labs prior to each visit.
  4. 3.       Acitretin (Soriatane®)
    1. This medication is a vitamin A analog with a possible anti-cancer and anti-aging effects
    2. Before starting this medication, it is important to do fasting baseline labs (lipid panel, complete blood count, and AST/ALT).
    3. Common side effects include:  sticky skin, dry skin, chapped lips, nail fragility, high cholesterol (if triglyceride is > 800, there is a risk of pancreatitis), pseudotumor cerebri (a severe form of headache that can be exacerbated by antibiotics such as, minocycline, tetracycline, and doxycycline), and bony spurs.
    4. This medication is not recommended for female at childbearing age because it can cause defect to the fetus.  Women have to wait 3 years after stopping the medication before she can get pregnant.
    5. The medication can come in 10 mg, 17.5 mg, 22.5 mg, or 25 mg, take daily with food
    6. Your dermatologist will ask you to get fasting labs every 3 months (same as baseline labs)
    7. Follow up with your dermatologist every 3 months